Texas Physicians Should Review New TMB Rules

Constant changes in medical board and other rules make it important that physicians and other health care providers stay up to date with new developments.  The Texas Medical Board, for instance, published a slew of new rules in March 2018 that impact Texas physicians and medical practice including many which provide relief from previously more burdensome maintenance of certification and other requirements..  Texas physicians should review these new rules for possible implications on their responsibilities or other aspects of their practice.

The following is a summary of the new Texas Medical Board Rules published in March, 2018, the full text of which may be found in the Texas Administrative Code here.


The amendments to §163.11, concerning Active Practice of Medicine, were adopted in accordance with Senate Bill 1148, adopted by the 85th Legislature, which prohibits the Board from requiring maintenance of certification by an applicant to be eligible for a medical license.

The amendments to §166.3, concerning Retired Physician Exception, and §166.6, concerning Exemption From Registration Fee for Retired Physician Providing Voluntary Charity Care, were adopted in accordance with Senate Bill 1148, adopted by the 85th Legislature, which prohibits the Board from requiring maintenance of certification by an applicant to be eligible for initial or renewal registration permit for a medical license.

The amendments to §172.12, concerning Out-of-State Telemedicine License, were adopted in accordance with Senate Bill 1148, adopted by the 85th Legislature, which prohibits the Board from requiring maintenance of certification by an applicant to be eligible for a medical license.


The amendments to §175.1, concerning Application and Administrative Fees, corrects language in paragraph (1)(H)(i) so that fees related to physician-in-training permits are lowered to $200. Further language is added outlining application and administrative fees for processing licenses for medical physicists, medical radiologic technologists, non-certified technicians, perfusionists, and respiratory care practitioners.

The amendments to §175.2, concerning Registration and Renewal Fees, adds language outlining renewal fees for continuing licenses, permits, and certificates for medical physicists, medical radiologic technologists, non-certified technicians, perfusionists, and respiratory care practitioners.

The amendments to §175.3, concerning Penalties, moves language providing an exemption for individuals serving as military members to new paragraph (11). The amendments further add language outlining penalty amounts for late renewals of licenses for perfusionists, respiratory care practitioners, medical physicists, and medical radiologic technologists.

The amendment to §175.5, concerning Payment of Fees or Penalties, amends language clarifying the rule’s allowance for fee refunds applies to applicants who timely withdraw applications, in addition to other requirements. Further language is added clarifying that refunds of fees may be granted to licensees who retire or request cancellation of their licenses within 90 days of paying a renewal fee.


The amendments to §177.18 (Subchapter E), concerning Purpose and Scope, and §177.20, concerning Call Coverage Minimum Requirements, and repeal of §177.19, concerning Definitions, provide a more flexible framework for call coverage agreements between physicians practicing in Texas so as to provide continuity of care to patients during a regular treating physician’s absence, while ensuring the covering physician’s accountability for meeting the standard of care and documenting the care provided during the call coverage period. The amendments eliminate the two-model approach under §177.20(b), allow all call coverage agreements to be contracted orally or in writing, and eliminate the requirement that certain agreements require real-time access to a patient’s medical records at the time of the call coverage period.


The amendments to §187.21(a), concerning Board and District Review Committee Members Participation, and §187.44(3), concerning Probationer Show Compliance Proceedings, correct the title of the reference to §187.18 of this chapter, which was recently changed to “ISC Scheduling, Process, and Procedures.”

The amendment to §187.76(c)(3), concerning Notice of Intention to Impose Administrative Penalty; Response, removes the undefined term “informal meeting” and replaces it with “ISC,” which is defined in §187.2 of this chapter (relating to Definitions). The amendment to §187.79, concerning Personal Appearance at an Informal Meeting, changes the title to “Personal Appearance at an ISC,” as “Informal Meeting” is not a defined term and “ISC” is a defined term and is the correct reference within the rule. The amendment in subsection (a) corrects the reference to “informal meeting” and replaces it with “ISC.” The amendment in subsection (b) also corrects the reference to “informal meeting” and replaces it with “ISC” and corrects the title of the reference to §187.18 of this chapter, which was recently changed to “ISC Scheduling, Process, and Procedures.” The amendment to §187.80(c), concerning Imposition of Administrative Penalty, removes the undefined term “informal meeting” and replaces it with “ISC,” which is defined in §187.2.


The amendments to §189.11, concerning Process for Approval of Physicians, Other Professionals, Group Practices and Institutional Settings, eliminates the words “or remedial plan” from the provision describing the mechanism under which the Board may require a licensee to practice with an approved physician or other professional to serve as a proctor, monitor, or supervisor or in an approved group practice or institutional setting, as §164.0015 of the Texas Occupations Code states that Remedial Plans may not contain provisions that limit or restrict a licensee’s practice.


The amendments to §183.4, concerning Licensure, add new language under subsection (a)(5) that allows an applicant for licensure to appear before the licensure committee of the Board to request reconsideration of the applicant’s ineligibility based on their failure to pass the NCCAOM examination within five attempts. Such amendment allows the Board discretion to reconsider such ineligibility determination. The proposed amendments delete obsolete language from subsection (a)(7). The proposed amendments to subsection (a)(9) provide an alternate mechanism to cure active practice issues faced by some licensure applicants. The remainder of the changes are corrections to punctuation and grammar.

The amendments to §183.19, concerning Acupuncture Advertising, remove language requiring that an acupuncturist include their license number on print advertising. The amendments to §183.20, concerning Continuing Acupuncture Education, add language to subsection (b)(1) to clarify the criteria for the courses from which the requisite CAE hours are taken. The proposed amendment adds new subsection (b)(2) to specify the number of CAE hours and specific topics which must be taken each year. New subsection (b)(3) is added to clarify the number of CAE hours from courses approved under each category delineated under subsection (b)(1). Spelling corrections were made in subsections (h) and (o).


The amendment to §186.2, concerning Definitions, adds new language under paragraph (41) that defines “voluntary charity care.”

The amendments to §186.4, concerning Procedural Rules and Qualifications for Certificate Applicants, add language to subsection (a)(2) to specify that application fees are set forth in 22 T.A.C. §175.1. The amendments also add language to subsection (g) to detail alternative certification procedures for military service members and military veterans, in addition to military spouses.

The amendments to §186.6, concerning Biennial Renewal of Certificate, add language to subsections (a), (d), and (j)(1) to reference specific rules in Chapter 175 that list certain fees.

The amendments to §186.7, concerning Temporary Permit, add language to subsection (a)(1) to detail that temporary permits issued under this subsection pertain to applicants who have signed an Agreed Order or Remedial Plan and are awaiting board approval. The amendments also add language to subsection (a)(3) to reference fees listed in 22 T.A.C. §175.1. Additionally, the amendments add language to subsection (c) to make clear that requirements listed in this subsection apply only to those applicants who have active practice issues. The amendments to §186.8, concerning Inactive Certificate, add language to subsection (a) to clarify that inactive certificates must be renewed each year.

The amendments to §186.10, concerning Continuing Education Requirements, add language to subsection (a) to state that at least two hours of the required 24 hours must be in the topic of ethics. Additionally, the amendments add subsection (b)(2) (C) to give non-traditional continuing education credit to those who teach or instruct a course in an accredited respiratory care educational program. The amendments also add language to subsection (b)(3) to clarify that credit may be awarded for credentialing or re-credentialing examinations listed in this subsection. The National Asthma Education Certification Board (NAECB) Certified Asthma Educator (AE-C) and neonatal resuscitation program (NRP) examinations are also added to this subsection. Language is also added to subsection (b)(3)(J) to explain how often credit may be awarded when the same examination is taken for initial credentialing purposes and recredentialing purposes.

The amendments to §186.13, concerning Identification Requirements, adds subsection (b) to require respiratory care practitioners holding a temporary permit to hold themselves out as temporary care practitioners or TRCPs.

The amendments to §186.17, concerning Grounds for Denial of Certification and for Disciplinary Action, adds language in paragraph (4) to make clear that disciplinary action or denial of certification based on criminal history is done in accordance with Chapter 53 of the Texas Occupations Code.

The amendments to §186.28, concerning Retired Certificate, adds language in subparagraph (2)(A) to reference the new definition of voluntary charity care adopted in 22 T.A.C. §186.2 (41).


The amendment to §194.3, concerning Meetings and Committees, deletes subsection (f) and language providing that the board may at a regular or special meeting remove the secretary from office upon a majority vote, with other amendments re-lettering the remaining subsections. Language related to licensure and disciplinary committee functions is revised to clarify that the committees do not draft rules, but rather review draft language prepared by staff. Amendments further add a new paragraph (4) to subsection (f), setting forth new rules related to the creation of a new Education Committee. The proposed committee’s functions include recommending rules to the full board regarding education and training requirements certification as a radiologic technologist or registration as a non-certified technician (NCT), continuing education requirements for renewal of a Texas MRT certificate or NCT registration, and standards for the approval or rescinding approval of radiologic technologist certificate education program curricular and instructors.

The amendments to §194.5, concerning Applicability of Chapter; Exemptions, delete language referring to §194.14 of this title (relating to Alternate Training Requirements for Podiatric Medical Assistants), reflecting the repeal of §194.14.

The amendments to §194.6, concerning Procedural Rules and Minimum Eligibility Requirements for Applicants for a Certificate or Placement on the Board’s Non-Certified Technician General Registry, amend language so that an applicant is not deemed per se ineligible for a certificate or registration, based upon action taken against another license issued by a licensing authority in this or another state that is subject to probation or other disciplinary action not involving revocation or suspension. The board will continue to have the authority to deny a certificate or placement on the general registry based upon all such action, regardless if it is an action not involving revocation or suspension, but the amendments will allow the board more discretion in certain cases. The amendments further delete language under subsection (c)(8) and move it to a new paragraph (2), maintaining the board’s discretion to consider the nature of any final disciplinary action, other than suspension or revocation, when determining whether to issue the certificate or other authorization.

Amendments to subsection (f)(3) and subsection (i), with language referring to §194.14 of this title, are deleted, to reflect the repeal of §194.14. Amendments to subsection (j) adding clarifying language to make it clearer that non-certified technicians must comply with the active practice requirements under the rules in order to show eligibility for placement on the general registry.

Amendment to subsection (l) makes corrections to typographical errors.

The repeal of §194.14, concerning Alternate Training Requirements for Podiatric Medical Assistants, was adopted to comport with S.B. 674, which amended Texas Occupations Code, Chapter 601, and eliminated dual registration for non-certified technicians by certain state licensing boards, including the Podiatry Board. The MRT Board will maintain a single set of minimum training requirements in order to obtain eligibility for placement on a general registry for non-certified technicians (NCT).

The amendment to §194.16, concerning Hardship Exemptions, amends language in order to comport with S.B. 674, which amended Texas Occupations Code, §601.203, so that in order to show that an applicant faces a hardship in hiring a certificate holder or NCT due to an inability to attract and retain medical radiologic technologists, the applicant must also show evidence that the location for which the hardship exemption is sought must be located in a county with a population of less than 50,000.

Amendments further delete subsection (b)(4)(B) (vi), so that the use of only a hand-held fluoroscope with a maximum operating capability of 65 kilovolts and 1 milliampere, or similar type of x-ray unit for upper extremities only, with the radiation produced by the radiographic equipment representing a minimal threat to the patient and the operator of the equipment, no longer qualifies for a hardship exemption. The basis for the repeal is that the use of such equipment should be performed by individuals who have completed minimum training and obtained registration as a NCT or certification as a MRT or LMRT.

The amendment to §194.17, concerning Dangerous or Hazardous Procedures, removes language referring to §194.14 of this title, reflecting the repeal of §194.14.

Physicians and others that may be impacted by TMB rules should check with the TMB monthly for possible changes that could impact their rules of practice.

About the Author

Recognized by her peers as a Martindale-Hubble “AV-Preeminent” (Top 1%) and “Top Rated Lawyer” with special recognition LexisNexis® Martindale-Hubbell® as “LEGAL LEADER™ Texas Top Rated Lawyer” in Health Care Law and Labor and Employment Law; as among the “Best Lawyers In Dallas” for her work in the fields of “Labor & Employment,” “Tax: Erisa & Employee Benefits,” “Health Care” and “Business and Commercial Law” by D Magazine, Cynthia Marcotte Stamer is a practicing attorney board certified in labor and employment law by the Texas Board of Legal Specialization and management consultant, author, public policy advocate and lecturer widely known for 30+ years of health industry and other management work, public policy leadership and advocacy, coaching, teachings, and publications.

Ms. Stamer’s legal, management, governmental affairs work and speaking and publications have focused on helping health industry, health benefit and other organizations and their management use the law, performance and risk management tools and process to manage people, performance, quality, compliance, operations and risk.

Highly valued for her rare ability to find pragmatic client-centric solutions by combining her detailed legal and operational knowledge and experience with her talent for creative problem-solving, Ms. Stamer supports these organizations and their leaders on both a real-time, “on demand” basis as well as outsourced operations or special counsel on an interim, special project, or ongoing basis with strategic planning and product and services development and innovation; workforce and operations management, crisis preparedness and response as well as to prevent, stabilize and cleanup legal and operational crises large and small that arise in the course of operations.

As core components of this work, Ms. Stamer helps health industry, health plans and insurers, health IT, life sciences and other health industry clients manage regulatory, contractual and other compliance; vendors and suppliers; Medicare, Medicaid, CHIP, Medicare/Medicaid Advantage, ERISA and other private payer and other terms of participation, medical billing, reimbursement, claims administration and coordination, and other provider-payer relations, contracting, compliance and enforcement; Form 990 and other nonprofit and tax-exemption; fundraising, investors, joint venture, and other business partners; quality and other performance measurement, management, discipline and reporting; physician and other workforce recruiting, performance management, peer review and other investigations and discipline, wage and hour, payroll, gain-sharing and other pay-for performance and other compensation, training, outsourcing and other human resources and workforce matters; board, medical staff and other governance; strategic planning, process and quality improvement; meaningful use, EMR, HIPAA and other technology,  data security and breach and other health IT and data; STARK, antikickback, insurance, and other fraud prevention, investigation, defense and enforcement; audits, investigations, and enforcement actions; trade secrets and other intellectual property; crisis preparedness and response; internal, government and third-party licensure, credentialing, accreditation, HCQIA and other peer review and quality reporting, audits, investigations, enforcement and defense; patient relations and care;  internal controls and regulatory compliance; payer-provider, provider-provider, vendor, patient, governmental and community relations; facilities, practice, products and other sales, mergers, acquisitions and other business and commercial transactions; government procurement and contracting; grants; tax-exemption and not-for-profit; 1557 and other Civil Rights; privacy and data security; training; risk and change management; regulatory affairs and public policy; process, product and service improvement, development and innovation, and other legal and operational compliance and risk management, government and regulatory affairs and operations concerns.

Her clients include public and private, domestic and international hospitals, health care systems, clinics, skilled nursing, long term care, rehabilitation and other health care providers and facilities; medical staff, accreditation, peer review and quality committees and organizations; billing, utilization management, management services organizations, group purchasing organizations; pharmaceutical, pharmacy, and prescription benefit management and organizations; consultants; investors; technology, billing and reimbursement and other services and product vendors; products and solutions consultants and developers; investors; managed care organizations, insurers, self-insured health plans and other payers; and other health industry clients to establish and administer compliance and risk management policies; comply with requirements, investigate and respond to Board of Medicine, Health, Nursing, Pharmacy, Chiropractic, and other licensing agencies, Department of Aging & Disability, FDA, Drug Enforcement Agency, OCR Privacy and Civil Rights, Department of Labor, IRS, HHS, DOD, FTC, SEC, CDC and other public health, Department of Justice and state attorneys’ general and other federal and state agencies; JCHO and other accreditation and quality organizations; private litigation and other federal and state health care industry investigation, enforcement including insurance or other liability management and allocation; process and product development, contracting, deployment and defense; evaluation, commenting or seeking modification of regulatory guidance, and other regulatory and public policy advocacy; training and discipline; enforcement, and a host of other related concerns for public and private health care providers, health insurers, health plans, technology and other vendors, employers, and others.and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns.

Author of leading works on a multitude of health care, health plan and other health industry matters, the American Bar Association (ABA) International Section Life Sciences Committee Vice Chair, a Scribe for the ABA Joint Committee on Employee Benefits (JCEB) Annual OCR Agency Meeting, former Vice President of the North Texas Health Care Compliance Professionals Association, past Chair of the ABA Health Law Section Managed Care & Insurance Section, past ABA JCEB Council Representative and CLE and Marketing Committee Chair, past Board President of Richardson Development Center (now Warren Center) for Children Early Childhood Intervention Agency, past North Texas United Way Long Range Planning Committee Member, and past Board Member and Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer’s health industry clients include public health organizations; public and private hospitals, healthcare systems, clinics and other health care facilities; physicians, physician practices, medical staff, and other provider organizations; skilled nursing, long term care, assisted living, home health, ambulatory surgery, dialysis, telemedicine, DME, Pharma, clinics, and other health care providers; billing, management and other administrative services organizations; insured, self-insured, association and other health plans; PPOs, HMOs and other managed care organizations, insurance, claims administration, utilization management, and other health care payers; public and private peer review, quality assurance, accreditation and licensing; technology and other outsourcing; healthcare clearinghouse and other data; research; public and private social and community organizations; real estate, technology, clinical pathways, and other developers; investors, banks and financial institutions; audit, accounting, law firm; consulting; document management and recordkeeping, business associates, vendors, and service providers and other professional and other health industry organizations; academic medicine; trade associations; legislative and other law making bodies and others.

Past Chair of the ABA Managed Care & Insurance Interest Group and, a Fellow in the American College of Employee Benefit Counsel, the American Bar Foundation and the Texas Bar Foundation, Ms. Stamer also has extensive health care reimbursement and insurance experience advising and defending health care providers, payers, and others about Medicare, Medicaid, Medicare and Medicaid Advantage, Tri-Care, self-insured group, association, individual and group and other health benefit programs and coverages including but not limited to advising public and private payers about coverage and program design and documentation, advising and defending providers, payers and systems and billing services entities about systems and process design, audits, and other processes; provider credentialing, and contracting; providers and payer billing, reimbursement, claims audits, denials and appeals, coverage coordination, reporting, direct contracting, False Claims Act, Medicare & Medicaid, ERISA, state Prompt Pay, out-of-network and other nonpar insured, and other health care claims, prepayment, post-payment and other coverage, claims denials, appeals, billing and fraud investigations and actions and other reimbursement and payment related investigation, enforcement, litigation and actions.

Heavily involved in health care and health information technology, data and related process and systems development, policy and operations innovation and a Scribe for ABA JCEB annual agency meeting with OCR for many years who has authored numerous highly-regarded works and training programs on HIPAA and other data security, privacy and use, Ms. Stamer also is widely recognized for her extensive work and leadership on leading edge health care and benefit policy and operational issues including meaningful use and EMR, billing and reimbursement, quality measurement and reimbursement, HIPAA, FACTA, PCI, trade secret, physician and other medical confidentiality and privacy, federal and state data security and data breach and other information privacy and data security rules and many other concerns. Her work includes both regulatory and public policy advocacy and thought leadership, as well as advising and representing a broad range of health industry and other clients about policy design, drafting, administration, business associate and other contracting, risk assessments, audits and other risk prevention and mitigation, investigation, reporting, mitigation and resolution of known or suspected violations or other incidents and responding to and defending investigations or other actions by plaintiffs, DOJ, OCR, FTC, state attorneys’ general and other federal or state agencies, other business partners, patients and others.

Ms. Stamer has worked extensively with health care providers, health plans, health care clearinghouses, their business associates, employers and other plan sponsors, banks and other financial institutions, and others on risk management and compliance with HIPAA, FACTA, trade secret and other information privacy and data security rules, including the establishment, documentation, implementation, audit and enforcement of policies, procedures, systems and safeguards, investigating and responding to known or suspected breaches, defending investigations or other actions by plaintiffs, OCR and other federal or state agencies, reporting known or suspected violations, business associate and other contracting, commenting or obtaining other clarification of guidance, training and and enforcement, and a host of other related concerns. Her clients include public and private health care providers, health insurers, health plans, technology and other vendors, and others. In addition to representing and advising these organizations, she also has conducted training on Privacy & The Pandemic for the Association of State & Territorial Health Plans, as well as HIPAA, FACTA, PCI, medical confidentiality, insurance confidentiality and other privacy and data security compliance and risk management for Los Angeles County Health Department, MGMA, ISSA, HIMMS, the ABA, SHRM, schools, medical societies, government and private health care and health plan organizations, their business associates, trade associations and others.

A former lead consultant to the Government of Bolivia on its Pension Privatization Project with extensive domestic and international public policy concerns in Pensions, healthcare, workforce, immigration, tax, education and other areas.

A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, privacy and data security, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns.

A Fellow in the American College of Employee Benefit Counsel, the American Bar Foundation and the Texas Bar Foundation, Ms. Stamer also shares her thought leadership, experience and advocacy on these and other related concerns by her service in the leadership of the Solutions Law Press, Inc. Coalition for Responsible Health Policy, its PROJECT COPE: Coalition on Patient Empowerment, and a broad range of other professional and civic organizations including North Texas Healthcare Compliance Association, a founding Board Member and past President of the Alliance for Healthcare Excellence, past Board Member and Board Compliance Committee Chair for the National Kidney Foundation of North Texas; former Board President of the early childhood development intervention agency, The Richardson Development Center for Children (now Warren Center For Children); current Vice Chair of the ABA Tort & Insurance Practice Section Employee Benefits Committee, current Vice Chair of Policy for the Life Sciences Committee of the ABA International Section, Past Chair of the ABA Health Law Section Managed Care & Insurance Section, a current Defined Contribution Plan Committee Co-Chair, former Group Chair and Co-Chair of the ABA RPTE Section Employee Benefits Group, past Representative and chair of various committees of ABA Joint Committee on Employee Benefits; a ABA Health Law Coordinating Council representative, former Coordinator and a Vice-Chair of the Gulf Coast TEGE Council TE Division, past Chair of the Dallas Bar Association Employee Benefits & Executive Compensation Committee, a former member of the Board of Directors of the Southwest Benefits Association and others.

For more information about Ms. Stamer or her health industry and other experience and involvements, see here or contact Ms. Stamer via telephone at (469) 767-8872 or via e-mail here.

About Solutions Law Press, Inc.™

Solutions Law Press, Inc.™ provides human resources and employee benefit and other business risk management, legal compliance, management effectiveness and other coaching, tools and other resources, training and education on leadership, governance, human resources, employee benefits, data security and privacy, insurance, health care and other key compliance, risk management, internal controls and operational concerns. If you find this of interest, you also be interested reviewing some of our other Solutions Law Press, Inc.™ resources here.

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NOTICE: These statements and materials are for general informational and purposes only. They do not establish an attorney-client relationship, are not legal advice or an offer or commitment to provide legal advice, and do not serve as a substitute for legal advice. Readers are urged to engage competent legal counsel for consultation and representation in light of the specific facts and circumstances presented in their unique circumstance at any particular time. No comment or statement in this publication is to be construed as legal advise or an admission. The author reserves the right to qualify or retract any of these statements at any time. Likewise, the content is not tailored to any particular situation and does not necessarily address all relevant issues. Because the law is rapidly evolving and rapidly evolving rules makes it highly likely that subsequent developments could impact the currency and completeness of this discussion. The presenter and the program sponsor disclaim, and have no responsibility to provide any update or otherwise notify any participant of any such change, limitation, or other condition that might affect the suitability of reliance upon these materials or information otherwise conveyed in connection with this program. Readers may not rely upon, are solely responsible for, and assume the risk and all liabilities resulting from their use of this publication.

Circular 230 Compliance. The following disclaimer is included to ensure that we comply with U.S. Treasury Department Regulations. Any statements contained herein are not intended or written by the writer to be used, and nothing contained herein can be used by you or any other person, for the purpose of (1) avoiding penalties that may be imposed under federal tax law, or (2) promoting, marketing or recommending to another party any tax-related transaction or matter addressed herein.

©2018 Cynthia Marcotte Stamer. Non-exclusive right to republish granted to Solutions Law Press, Inc.™ For information about republication, please contact the author directly. All other rights reserved.

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