ADOPTED RULES An agency may take final action on a section 30 days after a proposal has been published in the Texas Register. The section becomes effective 20 days after the agency files the correct document with the Texas Register, unless a later date is specified or unless a federal statute or regulation requires implementation of the action on shorter notice. If an agency adopts the section without any changes to the proposed text, only the preamble of the notice and statement of legal authority will be published. If an agency adopts the section with changes to the proposed text, the proposal will be republished with the changes. TITLE 19. EDUCATION Part I. Texas Higher Education Coordinating Board Chapter 21. Student Services Subchapter EE. Texas National Student Exchange Program 19 TAC sec.sec.21.990-21.999 The Texas Higher Education Coordinating Board adopts new sec.sec.21.990- 21. 999, concerning Texas National Student Exchange Program. Section 21.991 and sec.sec.21.993-21.996 are adopted with changes to the proposed text as published in the December 14, 1993, issue of the Texas Register (18 TexReg 9257). Sections 21.990, 21.992, 21.997, and 21.999 are adopted without changes and will not be republished. The new rules are required by passage of Senate Bill 846, 73rd Legislature. The rules will guide institutions of higher education in establishing student exchange agreements with other states. The rules will function by allowing students at participating schools to enroll for one year at an institution in another participating state yet retain resident status. Comments were made in reference to the rules being changed to make them more like the rules for the program as administered in other states. None of the changes were consequential but did help to clarify the meaning of the modified sections. The National Student Exchange commented in favor of the adoption of the rules. The agency agreed with the comments and changes were made as suggested. The new sections are proposed under Texas Education Code, sec.51.929, which provides the Texas Higher Education Coordinating Board with the authority to adopt rules concerning Texas National Student Exchange Program. sec.21.991. Administration. Institutions of higher education are responsible for administering the program in keeping with rules adopted by the board and in compliance with the institution's contract with National Student Exchange. sec.21.993. Eligible Students. (a) To participate in the exchange program a Texas student must be an undergraduate attending a Texas general academic teaching institution as defined in the Education Code, sec.61. 003(3). (b) To participate in the exchange program a student whose home institution is located outside of Texas must be an undergraduate. (c) A student may participate in the exchange program for no more than one 12-month academic year. sec.21.994. Tuition Charges. Participants in the exchange program are eligible to pay their normal tuition and fees charges at their home campus or resident tuition and fees at their host campus, depending upon procedures agreed upon by the two National Student Exchange participating institutions. sec.21.995. Transcripts. Course work at the host campus will be recorded on official transcripts of the host campuses. Students participating in the exchange will be responsible for arranging for copies of transcripts to be sent to their home campuses at the end of the exchange period. Courses and credit hours attempted and grades earned should be recorded on the student's home campus transcript. sec.21.996. Financial Aid. Students participating in the exchange program must receive any federally funded financial aid from the institution where tuition and fees are paid. If assistance is received from the host institution, such must be coordinated with any aid received from the home campus. This agency hereby certifies that the rule as adopted has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority. Issued in Austin, Texas, on March 3, 1994. TRD-9437088 James McWhorter Assistant Commissioner for Administration Texas Higher Education Coordinating Board Effective date: April 22, 1994 Proposal publication date: December 14, 1993 For further information, please call: (512) 483-6160 TITLE 22. EXAMINING BOARDS Part XXV. Structural Pest Control Board Chapter 593. Licensing 22 TAC sec.593.13 The Texas Structural Pest Control Board adopts new sec.593.13, without changes to the proposed text as published in the October 26, 1993, issue of the Texas Register (18 TexReg 7457). The justification is the rule creates greater efficiency in licensing the public employees and increased compliance with licensing requirements. The rule functions by creating a special vegetation management technician for employees of city, county and state government who engage in weed control. There will also be only one exam instead of two. The general and weed category will be combined. The Texas Vegetation Management Association commented in favor of adoption, because the proposed regulation is exempting the technician-apprentice license fee of $18. No comments against adoption were received. The amendment is adopted under Texas Civil Statutes, Article 135b-6, which gives the Texas Structural Pest Control Board the authority to license and regulate persons who provide structural pest control services. This agency hereby certifies that the rule as adopted has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority. Issued in Austin, Texas, on February 25, 1994. TRD-9437664 Benny M. Mathis, Jr. Executive Director Structural Pest Control Board Effective date: April 6, 1994 Proposal publication date: October 26, 1993 For further information, please call: (512) 835-4066 22 TAC sec.593.22 The Texas Structural Pest Control Board adopts an amendment to sec.593.22, without changes to the proposed text as published in the December 3, 1993, issue of the Texas Register (18 TexReg 8847). The justification is the rule creates greater ability to achieve required training. The rule functions by extending the official training and testing period for technician-apprentices to 12 months. The Texas Vegetation Management Association and the Texas Pest Control Association commented in favor of adoption of the rule because it extends the technician-apprentice license from six to 12 months. They felt six months was not adequate time in order to get an individual trained and tested to be a technician. There were no comments against adoption of the rule. The amendment is adopted under Texas Civil Statutes, Article 135b-6, which give the Texas Structural Pest Control Board the authority to license and regulate persons who provide structural pest control services. This agency hereby certifies that the rule as adopted has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority. Issued in Austin, Texas, on February 25, 1994. TRD-9437662 Benny M. Mathis, Jr. Executive Director Structural Pest Control Board Effective date: April 6, 1994 Proposal publication date: December 3, 1993 For further information, please call: (512) 835-4066 TITLE 25. HEALTH SERVICES Part I. Texas Department of Health Chapter 35. Pharmacy Services On behalf of the State Medicaid Director, the Texas Department of Health adopts amendments to sec.35.405 and sec.35.601. Section 35.601 is adopted with changes to the proposed section as published in the November 12, 1993, issue of the Texas Register (18 TexReg 8336). Section 35.405 is adopted without changes and will not be published. The sections cover quantity limitations and reimbursement in pharmacy services. The amendments allow pharmacy providers to make more efficient use of the new on-line, real-time billing system that began processing claims submissions in March, 1993. The new policies allow providers to submit claims for drugs purchased from a central purchasing entity; and impose a 50% of the previous amount of drug dispensed edit on all prescriptions instead of the previous 75%. If a claim fails the edit, it will be rejected and the provider will have to provide the help-desk with documentation of the reason for the early refill. No comments were received on the proposed rules. However, the Board recommended the language "Use a "9" code in the "Basis of Cost Determination" field (423) when billing these claims" be deleted in sec.35.601 because this language should properly be included in the instructions to the provider for reimbursements. Subchapter D. Limitations 25 TAC sec.35.405 The amendments are adopted under the Human Resources Code, sec.32.021 and Texas Civil Statutes, Article 4413 (502), sec.16, which provides the Health and Human Services Commission with the authority to adopt rules to administer the state's medical assistance program and are submitted by the Texas Department of Health under its agreement with the Health and Human Services Commission to operate the purchased health services program and as authorized under Chapter 15, sec.1.07, Acts of the 72nd Legislature, First Called Session (1991). This agency hereby certifies that the rule as adopted has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority. Issued in Austin, Texas, on March 16, 1994. TRD-9437656 Susan K. Steeg General Counsel, Office of General Counsel Texas Department of Health Effective date: April 6, 1994 Proposal publication date: November 12, 1993 For further information, please call: (512) 338-6967 Subchapter F. Reimbursement 25 TAC sec.35.601 The amendments are adopted under the Human Resources Code, sec.32.021 and Texas Civil Statutes, Article 4413 (502), sec.16, which provide the Health and Human Services Commission with the authority to adopt rules to administer the state's medical assistance program and are submitted by the Texas Department of Health under its agreement with the Health and Human Services Commission to operate the purchased health services program and as authorized under Chapter 15, sec.1.07, Acts of the 72nd Legislature, First Called Session (1991). sec.35.601. Legend and Nonlegend Medication. For all medication, legend and nonlegend, covered by the Vendor Drug Program and appearing in the Texas Drug Code Index (TDCI) and updates, the following requirements must be met. (1) Reimbursement to the pharmaceutical provider is based on estimated acquisition cost (EAC), verifiable by invoice audit, plus the department's currently established dispensing fee per prescription, or the usual and customary price charged the general public, whichever is lower. (2) Estimated acquisition cost is defined as wholesale estimated acquisition cost (WEAC) or direct estimated acquisition cost (DEAC), according to the pharmacist's usual purchasing source and the pharmacist's usual purchasing quantity, or as maximum allowable cost (MAC) for multisource products. All drug purchases from a central purchasing entity must be billed to the department as warehouse purchases. The WEAC is established by the department using the current redbook or redbook update, less a percentage representing routing discounts received by pharmacists on wholesales drug purchases. The WEAC may not exceed wholesaler cost, as supplied by drug manufacturers, plus a percentage markup representing wholesaler operating costs and profits. The DEAC is established by the department using direct price information supplied by drug manufactureres. Providers are reimbursed only at the DEAC on all drug products that are available from select manufacturers/distributors who actively seek and encourage direct purchasing. The TDCI is used as the reference from drugs included in the scope of benefits and for allowable package sizes. No acquisition cost is billed to the department for samples dispensed. (3) Reimbursement for nonlegend drugs is based on the usual and customary price charged to the general public or EAC, plus 50% of the EAC, whichever is lower. No dispensing fee is added to the price of nonlegend drugs, and 50% of the EAC may not exceed the assigned dispensing fee. This agency hereby certifies that the rule as adopted has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority. Issued in Austin, Texas, on March 16, 1994. TRD-9437657 Susan K. Steeg General Counsel, Office of General Counsel Texas Department of Health Effective date: April 6, 1994 Proposal publication date: November 12, 1993 For further information, please call: (512) 338-6967 Chapter 157. Emergency Medical Care The Texas Department of Health (department) adopts new sec.157.38 and sec.157.45, an amendment to sec.157.41, and the repeal of existing sec.157.45 and sec.157.76, concerning emergency medical services. Sections 157.38, 157.41, and 157.45 are adopted with changes to the text as proposed in the September 28, 1993 issue of the Texas Register (18 TexReg 6603). The department adopts the repeals as proposed. The sections establish continuing education (CE), certification, and recertification requirements for emergency medical services (EMS) personnel pursuant to the requirements of Chapter 773 of the Health and Safety Code. The sections define a new process for skills verification as it has been changed from a skills examination process. The sections describe the minimum requirements for continuing education for EMS personnel including specific content areas, minimum hourly requirements, reporting requirements, CE course approval requirements, and an audit process. Additionally, a written CE evaluation replaces the current recertification examination. A summary of comments received follows. One hundred and sixty-three comments were received on sec.157.38. One hundred and ten commenters supported the section and 42 individuals opposed it in its entirety. In addition, numerous individuals had specific comments about portions of the section. All associations commenting on the section were generally in favor of the section; however they expressed concerns, questions, and offered recommendations. The Texas EMS Advisory Council recommended adoption of the section. Comments specific to the issue are as follows: COMMENT: One commenter stated that EVOC (Emergency Vehicle Operators Course) is a trademark name and suggested that the term be changed to a generic phrase such as an emergency driving course. RESPONSE: The department agrees and reference to EVOC has been genericized. COMMENT: Two commenters stated that rural volunteers would find it extremely difficult to accrue enough Texas Department of Health (TDH)-approved CE hours to recertify. RESPONSE: The department disagrees. Many resources are being directed toward the provision of innovative CE modalities for EMS certificants with particular concern for those living in rural areas. COMMENT: One commenter said requiring 80% of all credit to be accrued from TDH-approved content areas will put a great burden on the rural EMS and small volunteer EMS systems. Even with computerization it will be difficult to keep up with credits in each category for all members. The burden will fall on the individual to be responsible for maintaining personal CE records. RESPONSE: The department disagrees. The ultimate responsibility for tracking and recording CE hours has always and will continue to rest with the individual certificant. It is a prerequisite of certification. Content areas are consistent with DOT knowledge objectives and methods of accruing hours are flexible and compatible with persons volunteering in rural communities. COMMENT: One commenter asked how standardized the exams would be. This commenter also stated that there is no provision for those persons who are presently in their last two years of certification to be responsible for substantive CE during this certification period. RESPONSE: The department agrees that persons in their last two years of certification will not begin reporting CE via the new system until recertification. Additionally, the department found this language in the rule to be confusing and the language has been rewritten. Examinations prepared by individual CE providers will not be standardized. COMMENT: One commenter suggested that a practice component be built into the rule for a certain number of the total required hours, indicating that it would give an opportunity to measure the integration of new information. RESPONSE: While the department agrees with the concept, present resources make the inclusion prohibitive because of inability to set up a monitoring/auditing process. COMMENT: Two commenters asked if TDH designed specific courses that will meet each category of the required CE minimum hours for recertification. RESPONSE: While there is not a specific course written for each category based on the minimum hours, course material in each content area is available. Additionally, many new approaches to gaining CE have been initiated such as computerized instruction, distance learning via satellite, mobile training unit, etc. COMMENT: One commenter asked that, since they were among the lowest paid professionals in health care, was there going to be some provision made to assist EMS personnel in the high cost of the above mentioned courses? He asked if there would be clear cut guidelines as to how ACLS, PHTLS, PPPC, etc. would be used and accepted as CE prior to the passing of the proposals. RESPONSE: Since the total number of CE hours has not changed, the cost should not increase appreciably for those persons who have been conscientious in the accrual of CE hours. Each of the courses will be divided according to content area with associated minimum hourly requirements. COMMENT: One commenter asked if the state was going to provide the classes for CE hours. The commenter also asked if tapes would still be available that would count towards CE contact hours. RESPONSE: Resources are being expended to provide innovative approaches to CE in rural communities and various methods are available including tapes. COMMENT: One commenter asked if the courses have been designed and how and where would they be made available to current state certified instructors. RESPONSE: New courses have not been designed specifically for CE. Coordinators may use published courses or pull material from that supported by DOT knowledge objectives. COMMENT: One commenter said that details of the content areas do not agree with nationally published standards. The paragraph is key to the CE rules because it specifies what area every hour of approved CE must cover, but it does not specify the knowledge objectives to be attained and therein lies its weakness. RESPONSE: The department disagrees. Content areas are related to the DOT knowledge objectives as are those of the National Registry. If a certificant meets the Texas CE requirements, they will also satisfy those of the National Registry. COMMENT: Two commenters said that specified minimum hour requirements for CE should be redefined as "Recommended Guidelines" that would allow for diversity of education with the approval of the regional director. RESPONSE: The department disagrees. Content areas and associated minimums were developed to allow flexibility for individual certificants. COMMENT: One commenter recommends that the process for revocation of CE approval be better described and the degree of discretion better delineated to avoid misunderstanding. RESPONSE: The department disagrees. Further discussion of process will appear in the CE manual. COMMENT: Several commenters requested that management courses be considered as an elective content area. RESPONSE: The department agrees and the section has been revised to reflect the change. Fifty-three comments were received on sec.157.41. All commenters were generally in favor of the section; however they expressed concerns, questions, and offered recommendations. The Texas EMS Advisory Council recommended adoption of the section with minor wording changes. Comments specific to the issue are as follows: COMMENT: Section 157.41(a)(5)(A)(v)(I) addresses which criteria will be used for satisfying CPR skills proficiency. One commenter said this requirement should be deleted. The current TDH skills examination criteria accomplish testing according to industry standards set by the American Heart Association so no change is needed. RESPONSE: The department disagrees. Since there is an industry standard there is no need for TDH to replicate the criteria. COMMENT: Section 157.41(a)(5)(A)(v)(II), gives the option of accepting a valid CPR card as evidence of CPR skills proficiency. One commenter said this option should be deleted. The proposed changes will decrease the quality of EMS certification. Because the American Heart Association (AHA) and the American Red Cross instructors are for the most part unregulated volunteers with little accountability, no effective means exists to ensure their technical competency, effectiveness of instruction, or compliance with testing requirements. A CPR card is also not verification of skills proficiency. RESPONSE: The department disagrees, but has changed the language of the rule to stress that acceptance of a CPR card in lieu of CPR training is strictly at the option of the course coordinator. Additionally, this option has become a national standard and will be included in the new Department of Transportation (DOT) curriculum. COMMENT: Section 157.41(a)(5) outlines requirements of skills proficiency verification. One commenter pointed out that this section does not stipulate that skills verification must be conducted by certified examiners, according to TDH criteria, and he is concerned that the rule would allow anyone to utilize any standard they want. RESPONSE: The department agrees and specific wording regarding state certified skills examiners and state skills criteria has been added to the rule. COMMENT: Section 157.41(a)(5)(C) lists skills which shall have proficiency verified for paramedic candidates. One commenter asked that dysrhythmia recognition be reinstated as a skill requiring proficiency verification because it is a vital and frequently utilized skill for the paramedic. RESPONSE: The department disagrees since dysrhythmia recognition is included within a megacode (advanced cardiac resuscitation). COMMENT: One commenter said the rule should be changed to authorize possession of a valid Advanced Cardiac Life Support (ACLS) card issued within the inclusive dates of the paramedic or paramedic completion course, but after the date upon which the course coordinator deems that teaching of all aspects of cardiology and cardiac pharmacology is complete, to fulfill the megacode requirement RESPONSE: The department disagrees. The commenter appears to be confusing course content work with skills proficiency documentation. Proficiency in megacode needs to be documented prior to certification and the rule merely offers the two methods of documentation that are acceptable. COMMENT: One commenter objects to ACLS course completion being used in lieu of a specific megacode verification. He explained that the AHA has explicitly indicated the purely educational nature of the ACLS program. He stated that the standard for successful completion of the ACLS megacode does not encompass the skills appropriate for an EMS responder. RESPONSE: The department disagrees. The skills and therapeutic modality that are needed in response to a cardiac arrest are the same in the field or in a medical facility. Five hundred and ninety seven comments were received on sec.157.45: 353 were in favor of the section as proposed, and 214 were opposed. Several commenters were representing large associations. Several expressed concerns with specific points in the rule. The associations opposed to the section are listed at the end of the comments. Comments specific to the issue are as follows. COMMENT: A commenter asked "What will be the effect on physicians if the recertification test is eliminated, particularly in the rural areas? How will the 25% who are initially failing the exam be identified if there is no test? Is it possible with the proposed CE rule to not be tested at all, eg: by getting all credits via conferences? Is doing away with the test in the best interest of patient care?" RESPONSE: The effect on physicians regarding elimination of recertification testing cannot be predicted from available data. Identification of those who would have failed the test will be left with medical directors and service providers who monitor and evaluate performance. Gaining CE without testing would be difficult and expensive but within the realm of possibility. Issue of public welfare is and continues to be debatable. COMMENT: Concerning sec.157.45(b)(1)(D), the reference regarding pass/fail should be removed based on the fact that the CE Evaluation is not intended to be an examination. RESPONSE: The department agrees and has removed all references to pass/fail throughout the rules, except for those sections describing the person who has lost their certification and is seeking reentry. A new sentence has been added which explains CE Evaluation. COMMENT: Concerning sec.157.45(b), a commenter wanted to know how he would be informed of the results of the CE Evaluation. RESPONSE: The department added paragraph (3), to indicate that the results of the CE evaluation along with information relevant to interpretation of the scores will be issued to the recertifying candidate, associated medical directors, providers, first responder organizations, and/or employers. COMMENT: A commenter felt that perhaps every four years is too frequent a requirement for re-certification. Please consider adopting a seven-year certification term. RESPONSE: The department disagrees because a four-year certification is a legislative mandate. COMMENT: A commenter asked "Has the state determined how many EMS systems will be left without an evaluation tool and what the cost will be to develop that tool in all these systems that are left without one?" RESPONSE: The department determined that there is no data available on these issues. COMMENT: Section 157.41(a)(5) articulates a skills proficiency standard required for initial certification for candidates in each of the four EMS personnel categories. Commenters stated that "although we recognize that proposed recertification in sec.157.45(b)(1)(C) stipulates the same verification requirement for recertification candidates, we hesitate to endorse these changes for two reasons: in the proposed rules there is no stipulation as to how the verification process will be conducted, and there is no designation of who will carry out this verification action." RESPONSE: The department agrees and this oversight has been corrected. COMMENT: Commenters felt that skills verification certificates should be valid for 180 days instead of 90 days prior to the certificant's expiration date. This expanded time zone will greatly improve the logistical capabilities of large agencies to renew certificants without requesting extensions, especially when many renewals are required in a short time period. RESPONSE: The department agrees that a 180-day timeframe seems reasonable for proving skills proficiency and the rule has been revised to reflect the change. COMMENT: Commenters objected to the elimination of the current practice of permitting individuals who fail to complete recertification requirements the option of attending a refresher course rather than taking an entire course over again. RESPONSE: The department agrees and the section has been amended to reflect alternative options for the recertification candidate who is not timely in meeting requirements. In addition to the changes made as a result of comments the department made minor editorial changes throughout the sections for clarification purposes. The following associations commented on each section as follows. Commenters generally in favor of sec.157.38 as proposed were Tarrant County EMS Providers Organization, Northeast Fire Training Association, Texas Ambulance Association, the State Association of Firefighters, Valley EMS Association, Consumers Union, East Texas Council of EMS Coordinators, and Grayson County EMS Committee. Several individuals were opposed to the section. Commenters generally in favor of sec.157.41 as proposed were Northeast Fire Training Association, State Association of Firefighters, East Texas Council of Coordinators, and Texas Ambulance Association. Commenters generally in favor of sec.157.45 as proposed were Valley EMS Association, Tarrant County EMS Providers Organization, Texas Ambulance Association, Northeast Fire Training Association, State Association of Fire Fighters, East Texas Council of Governments, and the Texas Chemical Council. Commenters opposed to sec.157.45 (as proposed) in its entirity were Consumers Union, Metroplex Emergency Physician Associates, Texas Medical Association, American Heart Association, Texas College of Emergency Physicians, American Association of Retired Persons, and the Harris County Medical Society. EMS Training and Course Approval 25 TAC sec.157.38 The rules are adopted under the Health and Safety Code, Chapter 773, which provides the Texas Board of Health with the authority to adopt rules to implement the Emergency Medical Services Act; sec.12.001, which provides the Texas Board of Health with the authority to adopt rules for the performance of every duty imposed by law on the Texas Board of Health, the Texas Department of Health, and the Commissioner of Health, and under sec.12.031 and sec.12.032, Health and Safety Code, which provides the Texas Board of Health with the authority to charge fees to a person who receives public health services, including administration services, from the department; Texas Civil Statutes, Senate Bill 312, 71st Legislature, 1989, which require the department to update and clarify existing rules and to establish new requirements through rulemaking. sec.157.38. Continuing Education. (a) Purpose. The purpose of this section is to establish the minimum continuing education (CE) requirements necessary for emergency medical services (EMS) personnel to maintain certification. These requirements are intended to keep the certificant knowledgeable of current techniques and practice, maintain the quality of emergency medical services provided to the public, and encourage improvement in the skill and competence of EMS personnel. (b) Hour requirements. CE is a requirement of sec.157.45 of this title (relating to Recertification). A contact hour shall consist of 50 consecutive minutes of attendance and participation in an approved CE experience. Credit hours for CE activities will only be awarded for the two-year time period in which they are completed. (1) Emergency Care Attendants (ECA) shall be required to document 20 contact hours of CE every two years, with a total of 40 contact hours within the four-year certification period. (2) Emergency Medical Technicians (EMT) shall be required to document 40 contact hours of CE every two years, with a total of 80 contact hours within the four-year certification period. (3) EMT-Intermediates (EMT-I) shall be required to document 60 contact hours of CE every two years, with a total of 120 contact hours within the four-year certification period. (4) EMT-Paramedics (EMT-P) shall be required to document 80 contact hours of CE every two years, with a total of 160 contact hours within the four-year certification period. (c) Content requirements. Candidates at each certification level shall at a minimum accrue the following CE hours during a two-year CE period. (1) At each certification level, at least 80% of required CE hours shall be accrued from the Texas Department of Health (department)-approved content areas with specified minimum hour requirements successfully completed. (2) The remaining 20% of required hours shall be accrued from any department-approved content areas. (3) Department-approved content areas with specified minimum hour requirements for each certification level are as follows. [graphic] (d) General criteria necessary for consideration of CE program approval. CE programs shall receive prior approval from the department if state CE credit is desired. A CE provider shall meet the following criteria for consideration of CE program approval. (1) The program shall be at least one contact hour in length. (2) Learner objectives shall be written and be the basis for determining content and evaluation. (3) The target audience for the program shall be identified. (4) The content shall be relevant to identified topic areas, and be related to and consistent with, program objectives. (5) The instructor shall be knowledgeable and competent in the subject matter taught. There shall be documentation of the instructor's expertise in the content area. (6) Learning experiences shall be appropriate to achieve the objectives of the program. Principles of adult education shall be used in the design of the program. (7) A schedule shall be provided which identifies the content areas covered and the number of contact hours awarded in each content area. (8) Facilities and educational resources shall be adequate to implement the program. (9) An evaluation tool shall be utilized which provides the participant an opportunity to comment on: (A) achievement of the objectives; (B) teaching effectiveness of each instructor; (C) relevance of content presented to stated objectives; (D) effectiveness of teaching methods; and (E) appropriateness of physical facilities and educational resources. (10) The grading system shall be appropriate for the type of program presented. (e) Types of CE programs and additional specific criteria necessary for consideration of CE approval. (1) Department-approved CE programs endorsed by national and state accrediting organizations. (2) Ongoing CE programs provided by department-approved EMS initial training programs, licensed EMS providers, or accredited educational institutions. (A) Approved EMS certification training programs that are categorized by the department as an Annual Program may receive approval for a two-year ongoing CE program upon completion and approval of a biennial CE application. (B) Licensed EMS providers who have a documented quality assessment plan with CE as part of their improvement plan and have a state-certified coordinator, instructor, or medical director who is responsible for the CE program, may receive approval for a two-year ongoing CE program upon completion and approval of a biennial CE application. (C) Acceptance of programs for CE credit shall depend on the provision of an appropriate and adequate written evaluation tool that covers the entire scope of objectives taught, with a minimum of a "Pass/Fail" grading system, in addition to the criteria listed in subsection (d) of this subsection. CE credit shall only be awarded if the individual receives a passing score. (D) Criteria for approval shall be subject to review and audit as part of a site visit of an EMS certification program or during a spot inspection of a licensed provider. (E) If a CE program is found to be deficient in meeting the approval criteria upon audit, then preapproval for the remaining period shall be revoked. After deficiencies have been corrected, each CE credit hour shall be individually approved by the department prior to presentation for the remainder of the two-year period. (3) National or state standardized courses and conferences. (A) National and state standardized courses such as Advanced Cardiac Life Support (ACLS), Basic Trauma Life Support (BTLS), Prehospital Trauma Life Support (PHTLS), Pediatric Advanced Life Support (PALS), and Pediatric Prehospital Provider Course (PPPC), all of which must have an adequate evaluation tool which covers the entire scope of objectives taught as part of the program, will be listed with preapproved credit hours assigned. A minimum of "Pass" on a "Pass/Fail" grading system shall be achieved and documented before credit can be awarded. An approved CE activity list of these programs shall be maintained by the department. (B) National and state conferences may be pre-approved based solely on the merit of content and subject matter experts and placed on the approved CE activity list with credit hours assigned. (4) Instructor-directed, single or multiple offering of the same activity, which is not included in paragraphs (1)-(3) of this subsection. (A) A program which is offered one or more times, such as a workshop, or seminar, shall complete all criteria listed in subsection (d) of this section and shall be approved prior to the delivery of the single activity or the initial delivery of the multiple-offering activity. Acceptance of programs for CE credit shall depend on the provision of an appropriate and adequate written evaluation tool that covers the entire scope of objectives taught, with a minimum of a "Pass/Fail" grading system. CE credit shall only be awarded if the individual receives a passing score. (B) Instructors of these programs are not required to be state certified instructors or coordinators, but shall have expertise in the content areas taught. (C) If the CE application is for a multiple-offering activity, then approval may be given for up to a two-year time period. (D) If the multiple-offering CE program is found to be deficient in meeting the approval criteria upon audit, then pre-approval for the remaining time period shall be revoked. After deficiencies have been corrected, then each CE credit hour for the remainder of the two-year period shall be individually approved before delivery. If a multiple-offering CE program is found to be deficient upon audit on more than one occasion, that program shall not be allowed to have pre-approval for more than one course at a time in the future. (5) Individualized instruction. If applicable to appropriate content areas, independent home study such as CE articles in EMS journals, CE packages from professional associations, and ongoing serial productions such as video magazines may count for up to 50% of the required CE hours per two-year period. Interactive programmed instruction such as computer programs, may count for all of the required CE hours per two years, if applicable to appropriate content areas. All individualized instruction programs shall: (A) receive approval prior to delivery; (B) be developed by a professional group such as an educational institution, corporation, professional association or other approved provider of continuing education; (C) involve the learner by requiring an active and appropriate response to the educational materials presented; (D) depend on the provision of an appropriate and adequate written evaluation tool that covers the entire scope of objectives taught, with a minimum of a "Pass/Fail" grading system. CE credit will only be awarded to the individual if that person achieves and documents a passing score; and (E) provide a record of completion which complies with subsection (f) of this section concerning records indicating completion of the program. (6) Authorship. (A) A candidate may receive CE credit for development and publication of a manuscript in a periodical. (B) The number of CE credit hours awarded for each article shall be determined by the department. (C) CE credit will be awarded in the appropriate content areas as related to the manuscript. Fifteen percent of the total CE hours required per two years may be obtained through this means. (D) Credit for publication will be awarded only once per two-year CE time period and the candidate must, upon audit, submit a letter from the publisher indicating acceptance or a copy of the published work. (7) Academic courses. (A) A candidate may receive CE credit for academic courses within the specified content areas for each level of certification. (B) Completion of academic course work shall be credited on the basis of up to 15 CE contact hours for each semester hour successfully completed, within appropriate content areas. Less than 15 hours may be awarded if the academic course content is only partially applicable to content areas. (C) Candidates shall achieve and document a grade of "C" or better, or a "Pass" in a "Pass/Fail" grading system. Upon audit, the individual shall be able to present an official transcript documenting this score. (8) Instruction in approved initial training and continuing education courses. (A) EMS personnel instructing in an approved initial training course or in an approved CE program may apply the contact hours of actual teaching to the appropriate content areas during the two-year CE period. (B) Additional hours earned above the acceptable hours per content area can not be used for subsequent periods. (9) CE by optional examination. (A) Candidates may receive CE credit for passing the National Registry of Emergency Medical Technicians written and practical examination for their current level of EMS personnel certification. (B) Passing the examination shall be credited on the basis of 20 contact hours for EMT level, 30 contact hours for EMT-I level, and 40 contact hours for EMT-P level. CE credit for passing the National Registry examination shall be an option only once during the four-year certification period. (C) If the candidate fails either the written examination, practical skills examination, or both, they shall retest in accordance with National Registry of Emergency Medical Technicians criteria. (D) If the candidate fails to pass the National Registry of Emergency Medical Technicians retest examination, or does not retest, no CE credit will be awarded. The candidate shall complete the required CE hours by a mechanism other than optional examination. (f) Records for the CE provider. (1) Records of programs shall be kept by the CE provider for a minimum period of five years from the date of completion. (2) Records shall include target audience, objectives and content areas with corresponding number of hours, outline of instructor qualifications, dates of instruction, teaching methods, evaluation tools, and a list of participants. (3) The CE provider shall furnish each participant documentation of completion specifying the CE provider, title, date and location of program, content areas and contact hours, and grades or Pass/Fail, if applicable. Documentation shall be identified on a course certificate, completion document, or a verification letter on official letterhead. (g) Reporting requirements. Continuing education requirements shall be fulfilled and reported on a two-year cycle. Implementation of this section shall begin on September 1, 1994. Certificants who have at least two years remaining in their certification period shall comply with the two-year reporting requirement for the last two years of the certification period. Certificants who have less than two years remaining in their certification period shall comply with the reporting requirement after becoming recertified. (h) Activities which are not acceptable as CE. The following activities do not fulfill the requirements necessary to receive continuing education credits: (1) CPR courses designed for lay persons; (2) orientation programs sponsored by the employing agency to provide specific information about the work setting, policies and procedures, on-the-job training, and equipment demonstration; (3) organizational activity such as serving on committees, councils, or professional organizations; (4) any program or activity which is not pre-approved in accordance with this section; (5) any experience which does not fit into the content areas specified for each level of certification; and (6) activities which have been completed more than once during the two-year CE time period. (i) Responsibilities of individual certificant. (1) It is the responsibility of certificants to select and participate in CE activities that will meet their educational needs in conjunction with the direction of their EMS medical director and/or provider, where appropriate. In addition, it is the responsibility of the certificant to determine if the continuing education is approved by the department. (2) Each certificant shall be responsible for maintaining their own CE records. These records shall document completion as evidenced by course certificates, verification letters written on official letterhead, or academic transcripts, and shall include faculty names, titles, dates, content, number of clock hours, and grades of "Pass/Fail", if applicable. The burden of proof of CE participation/completion shall rest solely on the certificant. EMS providers may choose to duplicate these records as a service to their EMS personnel. (3) These records shall be maintained by the certificant for a minimum of five years from the date of the application for recertification. Copies of documentation shall be submitted to the department within 15 days, if requested upon audit. (4) If participation is in a program in which grades are provided, a grade equivalent to a "C" or better shall be required or "Pass" on a "Pass/Fail" grading system to receive credit for CE. (5) Certificants attending approved national or state conferences/courses shall be responsible for distributing the CE hours within the appropriate content areas for the level of certification and in accordance with the approved CE list in subsection (e) of this section. (j) Audit. (1) The department shall randomly audit certificant's continuing education summary forms. Audits shall be conducted in a timely fashion on at least the minimum number of summary forms necessary to make the audit statistically valid. The department shall also randomly audit a statistically valid sampling of actual teaching during CE programs. (2) The department may audit the summary form of a specific certificant in response to a complaint, or if there is reason to suspect that a certificant may have falsified CE documentation. The department may also audit actual teaching during CE programs in response to a complaint, or if there is reason to suspect that a CE provider may not be providing their CE program in accordance with the submitted outline and objectives. (3) Falsification of CE documentation shall be cause for probation, suspension, or decertification as in sec.157.51 of this title (relating to Criteria for Emergency Suspension, Suspension, Probation and Decertification of an EMS Certificate); sec.157.19 of this title (relating to Emergency Suspension, Suspension, Probation, Revocation of a License, and Administrative Penalty); and sec.157.64 of this title (relating to Criteria for Suspension, Probation, and Decertification of Course Coordinator, Program Instructor, and/or Examiner Certification). (4) The department may audit any records of the CE provider. (k) Failure to complete required CE. (1) A certificant who has failed to complete the requirements for the initial two-year CE time period will be granted a 90-day extension period to complete and submit the required CE. Failure to complete and submit the CE requirements within that time frame shall be cause for emergency suspension until CE requirements are met. (2) A certificant who has failed to complete and submit all the CE requirements prior to the expiration of their certification may apply for late recertification in accordance with sec.157. 45(d) of this title (relating to Recertification). This agency hereby certifies that the rule as adopted has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority. Issued in Austin, Texas, on March 16, 1994. TRD-9437661 Susan K. Steeg General Counsel, Office of General Counsel Texas Department of Health Effective date: April 6, 1994 Proposal publication date: September 28, 1993 For further information, please call: (512) 834-6700 EMS Personnel Certification 25 TAC sec.157.41, sec.157.45 The amendment and new section are adopted under the Health and Safety Code, sec.773, which provides the Texas Board of Health with the authority to adopt rules to implement the Emergency Medical Services Act; sec.12.001, which provides the Texas Board of Health with the authority to propose rules to the performance of every duty imposed by law on the Texas Board of Health, the Texas Department of Health, and the Commissioner of Health; Texas Civil Statutes, Senate Bill 312, 71st Legislature, 1989, which requires the department to update and clarify existing rules and to establish new requirements through rulemaking. sec.157.41. Certification. (a) A candidate for certification shall: (1) be at least 18 years of age; (2)-(3) (No change.) (4) submit to the department the application and the following applicable nonrefundable fee. (A) An emergency medical technician-intermediate (EMT-I) and an emergency medical technician-paramedic (EMT-P) shall pay $75. (B) An emergency care attendant (ECA) and an emergency medical technician (EMT) shall pay $50. (C) An emergency medical services (EMS) volunteer shall pay no fee. However, if an individual receives compensation during the certification period, the exemption is inapplicable and the individual shall send to the department an application and prorated fee as follows: (i) for an EMT-I and EMT-P: (I) if the certificate has been in effect 12 months or less, the individual shall pay $75; (II) if the certificate has been in effect 13 months to 24 months, the individual shall pay $56.25; (III) if the certificate has been in effect 25 months to 36 months, the individual shall pay $37.50; or (IV) if the certificate has been in effect 37 months to 48 months, the individual shall pay $18.75; (ii) for an ECA or EMT: (I) if the certificate has been in effect 12 months or less, the individual shall pay $50; (II) if the certificate has been in effect 13 months to 24 months, the individual shall pay $37.50; (III) if the certificate has been in effect 25 months to 36 months, the individual shall pay $25; or (IV) if the certificate has been in effect 37 months to 48 months, the individual shall pay $12.50; (5) have documented evidence from a state-certified skills examiner using state skills criteria of skills proficiency as follows: (A) The ECA and EMT skills proficiency verification shall consist of: (i)-(iv) (No change.) (v) basic cardiopulmonary resuscitation (CPR) which shall be accomplished by one of the following options: (I) testing for CPR proficiency using American Heart Association (AHA) or American Red Cross (ARC) standards; or (II) at the discretion of a course coordinator, requiring each student to show proof of CPR proficiency as evidenced by AHA or ARC proof of completion of an AHA Provider Course C or its equivalent; and (vi) (No change.) (B) The EMT-I skills proficiency verification shall consist of the skills verification requirements for ECA and EMT in subparagraph (A) of this paragraph. In addition, the student shall demonstrate proficiency in the following skills: (i) peripheral venipuncture for fluid administration; (ii) utilization of the pneumatic antishock garment; and (iii) utilization of an endotracheal tube (infant and adult) and an esophageal intubation device for airway control. (C) The EMT-P skills proficiency verification shall consist of the skills verification requirements for an ECA, EMT, and EMT-I in subparagraphs (A) and (B) of this paragraph. In addition, the student shall demonstrate proficiency in the following skills: (i) emergency drug administration; (ii) defibrillation and cardioversion; and (iii) megacode (Possession of a valid Advanced Cardiac Life Support (ACLS) card issued within the inclusive dates of the paramedic or paramedic completion course or documentation issued by the course medical director based upon scenarios submitted with the course approval documents shall fulfill megacode proficiency requirements.) (6) achieve a passing grade of 70 on the department's certification examination and, in addition, achieve a passing grade of 70 on the critical components of the examination. (b) The department has final authority for scheduling all certification examination sessions. (c) A candidate shall complete the examination and retest, if necessary, for certification no later than 180 days after the course completion date. However, a candidate who fails the certification examination may retest one time provided a fee of $25, if applicable, accompanies the request for a retest. (d) If the application approval process is prolonged due to a felony/misdemeanor conviction investigation; the 180-day time period may be extended to accommodate the candidate who is deemed eligible to test. (e) (No change.) (f) A candidate shall be eligible to reapply for certification for up to two years following the course completion date, if: (1) the coordinator has documented successful completion of the course but the candidate has not completed the examinations within 180 days of the course completion date; or (2) (No change.) (3) the candidates described in this subsection shall complete a department-approved refresher course for the level of certification requested, submit the application for certification with the applicable fee, and complete all skills proficiency verification and examination requirements as described in subsections (a)(5)-(6) and (c) of this section. (g) A candidate who does not meet the requirements for certification within the two-year period following the course completion date shall be required to complete an entire EMS training course as described in sec.sec.157.32-157.35 of this title (relating to EMS Training Program and Course Approval) to be eligible to apply for certification. (h)-(j) (No change.) (k) The completion of a course at a higher level of certification shall satisfy the course requirement for a lower level of certification, and the individual may apply for certification by: (1) (No change.) (2) meeting the skills proficiency verification and examination requirements of this section within 180 days of the course completion date; or (3) meeting the requirements of subsection (e) of this section. (l) Individuals who successfully complete certification requirements for a higher level are deemed to be certified only at that level. (m) An individual who is certified as an EMT-I or EMT-P may voluntarily be certified at a lower level of certification by: (1) submitting an application for certification and the applicable fee, if any, as required in subsection (a)(3) and (4) of this section; (2) completing the requirements of sec.157.38 of this title (relating to Continuing Education) for the level of certification requested; (3) completing skills proficiency verification as required in subsection (a)(5) of this section: (4) achieving a passing grade on the department's written examinations as required in subsection (a)(6) of this section; and (5) returning the wallet-size certificate for the EMT-I or EMT-P level of certification to the department. sec.157.45. Recertification. (a) General. (1) At least 180 days prior to the expiration of a certificate, the Texas Department of Health's (department) Bureau of Emergency Management (bureau) shall mail a notice of expiration by United States mail to the certificant at the address shown in the bureau's records. It is the responsibility of emergency medical services (EMS) personnel to notify the bureau of any change of address. (2) If a certificant has not received notice of expiration from the bureau 45 days prior to the expiration, it is the duty of the certificant to notify the bureau and request an application for recertification. Failure to apply for recertification shall result in expiration of the certificate. (3) A certificate is not transferable. The wallet-size certificate shall be carried by personnel while on duty. A duplicate certificate may be issued following the submission of a request for duplicate certificate form and a fee of $5.00. (4) If the application approval process is prolonged due to a felony/misdemeanor conviction investigation, the 90-day time period in subsection (d)(1) and (2) of this section may be extended to accommodate the candidate who is deemed eligible for recertification. (b) Timely recertification. (1) A certificant shall meet the following requirements for recertification. The certificant shall: (A) complete the continuing education (CE) requirements for recertification as required in sec.157.38 of this title (relating to Continuing Education) prior to the expiration of the certificate and prior to meeting the requirement in subparagraph (D) of this paragraph; (B) submit to the department an application for recertification and the nonrefundable fee as set out in sec.157. 41(a)(4) of this title (relating to Certification); (C) successfully complete verification of skills proficiency as described in sec.157.41(a)(5) of this title; and (D) complete the department's CE evaluation which shall be an attempt to measure the individual's knowledge necessary for the adequate provision of emergency care for current level of certification. The department has final authority for scheduling all written CE evaluation sessions. (2) After verification by the department of the information submitted by the certificant, a certificant who meets requirements of this subsection will be recertified for four years commencing on the day following the expiration date of the most recent certificate. A new certificate and wallet-sized certificate signed by department officials shall be issued. (3) The results of the CE evaluation along with information relevant to interpretation of the scores will be issued to the recertifying candidate, associated medical directors, providers, first responder organizations, and/or employers. (4) One re-evaluation may be taken. A fee of $25 shall accompany the request for a re-evaluation. The re-evaluation results will be issued as in paragraph (3) of this subsection. (5) In conjunction with the certificant's two-year interim CE reporting cycle, the certificant may elect to complete the CE evaluation or the certificant's medical directors, providers, first responder organizations and/or employers may mandate that the certificant complete the CE evaluation and, if applicable, one re-evaluation. The first CE evaluation shall be completed within 180 days from the deadline date of the interim two-year reporting cycle. The re-evaluation may be completed after the 180-day period. The CE evaluation results will be issued as described in paragraph (3) of this subsection. (6) To take a two-year interim CE evaluation, the certificant shall submit an application, and a non-refundable fee as set out in sec.157.41(a)(4) of this title. A fee of $25 shall accompany the request for a re-evaluation. (c) Early recertification. (1) If a certificant requests to recertify prior to the 180-day notice, the certificant shall meet all the requirements of subsection (b) of this section within 90 days of the application date. (2) An application for a lower level of certification may be submitted with the applicable fee as described in subsection (b)(1)(B) of this section if the certificant meets the requirements for the level of certification requested as described in subsection (b)(1)(A) and (C) of this section. (3) A certificant who meets the requirements of this subsection shall be recertified for four years commencing on the date of issuance of a new certificate and wallet-sized certificate signed by department officials. (d) Late recertification. (1) If the application and the non-refundable fee for recertification are postmarked at least 30 days prior to the expiration date of the certificate, the certification shall continue for a period not to exceed 90 days from the expiration date. The applicant shall qualify for recertification by: (A) completing the CE requirements for recertification as required in sec.157.38 of this title; and (B) meeting the certification requirement as described in subsection (b)(1)(C) and (D) of this section no later than 90 days from the expiration date. (2) If an application and the non-refundable fee for recertification, including a $25 late fee, are postmarked less than 30 days before the expiration date but within 90 days following the expiration date, the applicant shall qualify for recertification by: (A) completing the CE requirements for recertification as required in sec.157.38 of this title; and (B) meeting the certification requirement as described in subsection (b)(1)(C) and (D) of this section no later than 90 days from the expiration date. Certification shall not continue during the 90-day period. (3) If an application, and non-refundable fee, for recertification is received after the 90-day period beyond the expiration date of the certificate, but within one year following the expiration date, the applicant shall submit, in addition to the recertification fee, a non-refundable late fee of $25. The applicant is not certified during this period. If he represents himself as a certified EMS person, the applicant may be denied recertification and may be subject to the civil and criminal penalties under the Health and Safety Code, sec.773.063 and sec.773.064. (A) All requirements in paragraph (3)(B)(i) and (ii) of this subsection shall be completed no later than one year from the expiration date of the most recent certificate. (B) The applicant shall qualify for recertification by successfully: (i) completing the CE requirements for recertification as required in sec.157.38 of this title no earlier than two years prior to the application; (ii) completing verification of skills proficiency as described in sec.157. 41(a)(5) of this title; and (iii) achieving a passing grade on the certification examination as required in sec.157.41(a)(6) of this title and on each critical subscale. An applicant who fails the certification examination may retest one time, provided a fee of $25, if applicable, accompanies the application for retest. (C) A candidate who does not successfully complete the recertification requirements in subparagraphs (A) and (B) of this paragraph shall meet the requirements of sec.157.41 of this title prior to being eligible for certification. (4) If an application and non-refundable fee for certification and a non-refundable late fee of $25 is received more than one year following the expiration date but within two years following the expiration date, the applicant shall qualify for recertification by completing the requirements in subsection (f)(1)(A)(i), (B)(i), or (C)(i) of this section for the appropriate level of certification. To receive credit, these requirements must be completed no earlier than two years prior to the application. (A) Candidates completing the requirement of this subsection shall achieve a passing grade on the certification examination as required in sec.157.41(a)(6) of this title and on each subscale. An applicant who fails the certification examination may retest one time provided a fee of $25 accompanies the application for a retest. (B) All requirements shall be completed within two years from the expiration date of the most recent certification. (C) A candidate who does not successfully complete the recertification requirements in this subsection shall meet the requirements of sec.157.41 of this title prior to being eligible for certification. (e) Inactive status. A certified emergency medical technician (EMT), EMT-Intermediate (EMT-I), or EMT-Paramedic (EMT-P) not actively engaged in the provision of emergency medical services may make application to the department for inactive status. (1) While on inactive status, a person shall not perform any activities regulated under the Health and Safety Code, Chapter 773. Performance in any capacity for compensation or as a volunteer is prohibited and failure to comply shall be cause for decertification. Nothing in this section shall be construed to prohibit a person from performing first aid or cardiopulmonary resuscitation (CPR) in the capacity of a lay person. (2) While on inactive status, a person shall not be required to complete the CE requirements, skills verification, or complete the CE evaluation. (3) To maintain certification, the certificant shall submit to the department an application for recertification and the nonrefundable fee as set out in sec.157.41(a)(4) of this title, prior to the expiration of the current certificate. (f) Re-entry into active status. (1) To regain active status a certificant shall complete the following requirements prior to submitting an application and fee as set out in sec.157.41(a)(4) of this title for re-entry into active status. All requirements shall be completed within the two years prior to the application. (A) Paramedics. (i) The paramedic shall successfully complete: (I) a department-approved refresher course or equivalent CE in patient content areas; (II) an advanced Basic Trauma Life Support (BTLS) or Prehospital Trauma Life Support (PHTLS) course; (III) a Prehospital Pediatric Provider Course (PPPC) course; (IV) an Advanced Cardiac Life Support (ACLS) course; and (V) skills proficiency verification. (ii) The paramedic shall achieve a passing grade on the certification examination as in sec.157. 41(a)(6) of this title and on each critical subscale. A candidate who fails the examination may retest one time provided a fee of $25, if applicable, accompanies the application for a retest. If the applicant fails the retest, they shall no longer be certified. (B) EMT-I. (i) The EMT-I shall successfully complete: (I) a department-approved refresher course or equivalent CE in patient content areas; (II) an advanced BTLS or PHTLS course; (III) a PPPC course; (IV) an American Heart Association (AHA) Provider Course C or its equivalent; and (V) skills proficiency verification. (ii) The EMT-I shall achieve a passing grade on the certification examination as in sec.157.41(a)(6) of this title and on each critical subscale. A candidate who fails the examination may retest one time provided a fee of $25, if applicable, accompanies the application for a retest. If the applicant fails the retest, they shall no longer be certified. (C) EMT. (i) The EMT shall successfully complete: (I) a department-approved refresher course or equivalent CE in patient content areas; (II) a BTLS or PHTLS course; (III) a PPPC course; (IV) an AHA Provider Course C or its equivalent; and (V) a skills proficiency verification. (ii) The EMT shall achieve a passing grade on the certification examination as in sec.157.41(a)(6) of this title and on each critical subscale. A candidate who fails the examination may retest one time provided a fee of $25, if applicable, accompanies the application for a retest. If the applicant fails the retest, they shall no longer be certified. (2) After verification by the department of the information submitted by the candidate, a candidate who meets the requirements in paragraph (1)(A), (B) or (C) of this subsection shall be recertified for active status for four years commencing on the date of issuance of a new certificate and wallet-sized certificate signed by department officials. (3) The applicant who fails the test and retest and reapplies for certification shall meet the requirements of sec.157. 41 of this title prior to becoming certified. They shall not continue in inactive capacity. (g) Military personnel. An individual who fails to renew certification within 90 days of the expiration date because of active duty serving outside the State of Texas, shall have one year from the date of return to the state in which to: (1) complete department-approved CE requirements; as outlined in sec.157.38 of this title; (2) submit an application to the department and the nonrefundable fee as set out in sec.157. 41(a)(4) of this title; (3) complete the skills verification process as described in sec.157.41(a)(5) of this title; and (4) complete the CE evaluation as described in subsection (b) of this section. (h) Hardship cases. The bureau chief may review special hardship cases and allow a candidate additional time to complete requirements beyond the two-year CE reporting deadline or certification expiration date. Although additional time may be allowed to complete requirements, certification shall not continue beyond the certification expiration date. This agency hereby certifies that the rule as adopted has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority. Issued in Austin, Texas, on March 16, 1994. TRD-9437660 Susan K. Steeg General Counsel, Office of General Counsel Texas Department of Health Effective date: April 6, 1994 Proposal publication date: November 28, 1993 For further information, please call: (512) 834-6700 25 TAC sec.157.45 The repeal is adopted under the Health and Safety Code, sec.773, which provides the Texas Board of Health with the authority to adopt rules to implement the Emergency Medical Services Act; sec.12.001, which provides the Texas Board of Health with the authority to propose rules to the performance of every duty imposed by law on the Texas Board of Health, the Texas Department of Health, and the Commissioner of Health; Texas Civil Statutes, Senate Bill 312, 71st Legislature, 1989, which require the department to update and clarify existing rules and to establish new requirements through rule making. This agency hereby certifies that the rule as adopted has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority. Issued in Austin, Texas, on March 16, 1994. TRD-9437659 Susan K. Steeg General Counsel, Office of General Counsel Texas Department of Health Effective date: April 6, 1994 Proposal publication date: September 28, 1993 For further information, please call: (512) 834-6700 EMS Medical Services-Part B 25 TAC sec.157. 76 The repeal is adopted under the Health and Safety Code, sec.773, which provides the Texas Board of Health with the authority to adopt rules to implement the Emergency Medical Services Act; sec.12.001, which provides the Texas Board of Health with the authority to propose rules to the performance of every duty imposed by law on the Texas Board of Health, the Texas Department of Health, and the Commissioner of Health; Texas Civil Statutes, Senate Bill 312, 71st Legislature, 1989, which requires the department to update and clarify existing rules and to establish new requirements through rule making. This agency hereby certifies that the rule as adopted has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority. Issued in Austin, Texas, on March 16, 1994. TRD-9437658 Susan K. Steeg General Counsel, Office of General Counsel Texas Department of Health Effective date: April 6, 1994 Proposal publication date: September 28, 1993 For further information, please call: (512) 834-6700 TITLE 28. INSURANCE Part I. Texas Department of Insurance Chapter 7. Corporate and Financial Regulation Subchapter A. Examination and Corporate Custodian and Tax 28 TAC sec.7.7 The Texas Department of Insurance adopts amendments to sec.7.7, concerning subordinated indebtedness, surplus debentures, surplus notes, premium income notes, bonds or debentures, and other contingent evidences of indebtedness. The amendments are adopted with changes to the proposed text as published in the December 21, 1993, issue of the Texas Register (18 TexReg 9819). The amendments are necessary to implement amendments to Insurance Code, Article 1.39, enacted by the passage of House Bill 1461, 73rd Legislature, 1993. The amendments to Insurance Code, Article 1.39, established a minimum surplus or floor as a condition to an insurer paying interest or principal on subordinated indebtedness, repealed the requirement that the commissioner approve the issuance of subordinated indebtedness by an insurer, authorized property other than that authorized under sec.7.7(b)(2), provided that the agreement creating the subordinated indebtedness controls the accounting treatment of the indebtedness, and prescribes the accounting treatment for sinking funds established in connection with the creation of subordinated indebtedness. The adopted amendments redefine the minimum surplus or floor consistent with the amended statute, add a definition of "property" to expand the consideration an insurer may receive for the issuance of subordinated indebtedness, provide that an amount accumulated in a sinking fund is a legal liability and a financial statement liability, provide for an insurer to notify the department of the issuance of any subordinated indebtedness, and provide that an insurer that holds subordinated indebtedness of another insurer may report it in its financial statements as an asset equal to the amount then due and payable under the agreement creating the subordinated indebtedness. One commenter stated that the amendment to sec.7.7(c)(4) was more restrictive than the amended Insurance Code, Article 1.39, because it limited a sinking fund to insurance premium income. Staff agrees with the comment and has amended the section to conform with the statute. The commenter also stated the amendments to the section made no reference to the authority granted in Insurance Code, Article 1.39, to return any portion of the accumulated funds in a sinking fund to the surplus of an insurer. Staff does not believe it is necessary to restate this provision in the section. The commenter also stated that there was no justification for subparagraphs (6) and (7) of sec.7.7. The subparagraphs require an insurer to send notices to the department in connection with the issuance of subordinated debt or the payment of interest or principal on such debt. The section has been amended to delete the notice for payment of principal or interest. Staff believes the requirement is authorized under Insurance Code, 1.03A, as it is necessary for the department to know on a timely basis that an insurer has increased its surplus by borrowing. Such transactions have frequently been related to an insurer encountering problems with its financial condition. The Texas Department of Insurance received written comments from the Texas Legal Reserve Officials Association, a trade association composed of Texas domiciled life, health and accident insurance companies, and the law firm of Weil, Gotshal and Manges on behalf of certain insurance clients. The Texas Legal Reserve Officials Association requested a public hearing, but withdrew the request as a result of the changes. The amendments are adopted under the authority of Insurance Code, Articles 1.39, 1.11 and 1.03A. Article 1.39 regulates the issuance of subordinate indebtedness. Article 1.11 authorizes changes in the forms of the annual statement required of insurance companies. Article 1.03A provides the commissioner with the authorization to adopt rules and regulations for the conduct and execution of the duties and functions by the department. The following articles of the Insurance Code are affected by this rule: Articles 1.11, 1.29, 1.39, 11.16, 17.17, 19.07 and 21.49-1. sec.7.7. Subordinated Indebtedness, Surplus Debentures, Surplus Notes, Premium Income Notes, Bonds, or Debentures, and Other Contingent Evidences of Indebtedness. (a) Definitions. The following words and terms, when used in this section, shall have the following meanings, unless the context clearly indicates otherwise. (1) (No change.) (2) Minimum surplus or floor-The amount of surplus specified in the written agreement evidencing the subordinated indebtedness which may not be used for payments or repayments of subordinated indebtedness and which amount must exceed the greater of the following: (A) a minimum surplus stated and fixed in the agreement; or (B) a minimum surplus of $500,000 for that insurer. (3) Property-Any asset of readily determinable value that is an authorized and otherwise qualifying investment for the insurer issuing the subordinated indebtedness. (4) Subordinated indebtedness-Any contingent indebtedness issued by an insurer for which such insurer assumes a subordinated liability for repayment of principal and payment of interest pursuant to a written agreement providing for payment only out of that portion of an insurer's surplus that exceeds a minimum surplus stated in such agreement. Subordinated indebtedness includes advances made in accordance with the Insurance Code, Articles 11.16, 17.17 and 19.07, and surplus notes, as herein defined. (5) Surplus notes-Surplus notes, also known as "surplus debentures", "contribution certificates," "surplus capital notes," and "premium income notes, bonds, or debentures," however denominated, which are financing vehicles that increase the surplus of an insurer. (b) General Provisions. (1) (No change.) (2) The consideration received by an insurer in return for the issuance of subordinated indebtedness shall be in the form of cash, cash equivalent securities, government backed obligations, or property of readily determinable value. In the instance of an issuer required by the department to increase its surplus as regards policyholders, the subordination of a current liability owed by the issuer to the prospective holder of the subordinated indebtedness, may be considered in an amount acceptable to the commissioner. (3) Any agreement made pursuant to the Insurance Code, Article 1.39, and this section, shall be subject to other applicable provisions of the Insurance Code, including Articles 1.29 and 21.49-1. (c) Written Agreements. When issuing subordinated indebtedness, the insurer must execute a written agreement with the creditor, providing the following: (1) (No change.) (2) the minimum surplus or floor shall exceed the greater of the following: (A) a minimum surplus stated and fixed in the agreement; or (B) a minimum surplus of $500,000 for that insurer; (3) repayment provisions shall be clearly set forth in the written agreement; (4) if the subordinated indebtedness is in the form of a premium note, bond, or debenture, which includes a provision for the payment or repayment only out of a sinking fund established by the insurer by setting aside a specified amount during a specified period, all payments must be made from the established sinking fund, subject to the minimum surplus stated in the written agreement, and such amount accumulated and held in the sinking fund shall be a legal liability and financial statement liability of the insurer; (5) in the event of liquidation, payment of interest and repayment of principal under the written agreement are subordinated to policyholder and beneficiary claims; and (6) an insurer which is the issuer of such an agreement, if not an affiliate as defined in the Insurance Code, Article 21.49-1 of the creditor, shall notify in writing within ten days of issuance, the Financial Analysis Unit, Mail Code 303-1A, Texas Department of Insurance, P.O. Box 149099, 333 Guadalupe, Austin, Texas 78714-9099, and provide a copy of the written agreement for informational purposes. (d) Accounting Requirements. (1) A loan or advance made under the written agreement, and any interest accruing on the loan or advance, is a legal liability and financial statement liability of the insurer only to the extent provided by the terms and conditions of the loan or advance agreement, and the loan or advance may not otherwise be a legal liability or financial statement liability of the insurer. If a written agreement provides specific terms for the payment of principal and interest, and such terms have been satisfied, then any provision providing that no financial statement liability exists shall be considered to be in conflict with the specific terms for the payment of principal and interest; and, for financial statement purposes, the terms for the payment of principal and interest shall result in the reflection of a financial statement liability. (2) All agreements shall be clearly reported in an insurer's "Notes to Financial Statements" of the Annual Statement and shall disclose all pertinent aspects of payment and prepayment provisions. (3) An insurer holding a subordinated indebtedness of another insurer may report it as an admitted asset equal to the amount then due and payable under the terms of the subordinated indebtedness agreement. (e) Applicability to Foreign Insurers. The provisions of this section shall apply to insurers domiciled in another state unless such other state regulates the issuance of subordinated indebtedness under laws, rules, or bulletins that the commissioner finds are substantially similar in substance and effect to Texas law and rules. To pursue this exception, the insurer shall provide, upon request, to the commissioner evidence of similarity in the form of statutes, regulations, and interpretation of the standards utilized by the state of domicile. This agency hereby certifies that the rule as adopted has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority. Issued in Austin, Texas, on March 16, 1994. TRD-9437673 Linda K. von Quintus-Dorn Chief Clerk Texas Department of Insurance Effective date: April 6, 1994 Proposal publication date: December 21, 1993 For further information, please call: (512) 463-6327 28 TAC sec.7.83 The Texas Department of Insurance adopts an amendment to sec.7.83, concerning the open records treatment of examination reports, without changes to the proposed text as published in the December 14, 1993, issue of the Texas Register (18 TexReg 9258). The 73rd Legislature, 1993, amended Insurance Code, Article 1.15 by adding sec.9 which provides that examination reports are confidential and are not subject to disclosure under Government Code, sec.sec.552.001-552.353 (Open Records Act). This new law conflicts with the existing sec.7.83, which makes adopted examination reports open records, therefore it is necessary to amend the section to remove the conflict. Section 7.83 establishes a procedure for the department and an insurer to resolve any disagreements on findings in the examination report of an insurer. Prior to the adoption of the amendments the section provided that an examination report became a public record if a company did not appeal an examination report or the procedure to resolve any disagreements was completed. The amendment eliminates the provision that examination reports will become public when the procedure is completed and therefore will not be available to the public. Examination reports which have been made public under the rule in the past will remain public. No comments were received regarding adoption of the rule. The amendment is adopted under the Insurance Code, Articles 1.15 and 1.03A. Article 1.15 requires the department to adopt rules governing the procedure for the adoption of examination reports. Article 1.03A authorizes the Commissioner to determine rules for general and uniform application for the conduct and execution of the duties and functions of the department. This agency hereby certifies that the rule as adopted has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority. Issued in Austin, Texas, on March 16, 1994. TRD-9437675 Linda K. von Quintus-Dorn Chief Clerk Texas Department of Insurance Effective date: April 6, 1994 Proposal publication date: December 14, 1993 For further information, please call: (512) 463-6327 28 TAC sec.7.84 The Texas Department of Insurance adopts new sec.7.84, concerning the frequency of examinations of insurance carriers. The new section is adopted with changes to the proposed text as published in the December 21, 1993, issue of the Texas Register (18 TexReg 9821). The adopted section is necessary to implement an amendment to Insurance Code, Article 1.15, made by House Bill 1461, 73rd Legislature, 1993, that authorizes the commissioner to extend the interval between statutorily-required examinations of insurance carriers. The amendment directs the commissioner to adopt rules governing the determination of whether the financial strength of a carrier justifies deferment of an examination. The adopted section defines certain terms used in the section, describes the applicability of the section and describes the conditions that must exist for the commissioner to make a determination that the insurance carrier's financial strength justifies deferment of an examination. The associate commissioner for the Financial Program of the Texas Department of Insurance will review each carrier due for a regular examination to determine whether the carrier's financial strength justifies a deferment of the regular examination. The commissioner may defer the regular examination for one year if the conditions in the adopted rule have been met at all times subsequent to the last regular examination. One commenter stated that sec.7.84(c)(2) discriminates against carriers that do not have annual independent audits under Insurance Code, Article 1.15A. The department recognizes that an insurer that has an audit performed in the same manner as an audit is performed under Insurance Code, Article 1.15A should have equal recognition in meeting the conditions for a deferment. The paragraph is amended to include such audits. The commenter also suggested that sec.7.84(c)(2) be amended to provide that material adverse conditions, instead of adverse conditions, be the basis for not deferring an examination. The department agrees and the paragraph is amended to provide that material adverse conditions reported in an annual independent audit can be a basis for not deferring an examination. The commenter suggested that sec.7.84(c)(6) be deleted or amended to focus on current operations. The department disagrees. A negative balance in a carrier's unassigned funds account indicates management's inability to operate a carrier in a consistently profitable manner. The Texas Department of Insurance received a request for public hearing on the section and written comments from the Texas Legal Reserve Officials Association, a trade association composed of Texas-domiciled life, health and accident insurance companies. The request for public hearing was withdrawn as a result of the changes made to the rule. The new section is adopted under the authority of the Insurance Code, Articles 1.15, and 1.03A; and the Government Code, sec. sec.2001.004-2001.038. Article 1.15 authorizes the commissioner to adopt rules governing the determination of the financial strength of a carrier for the purpose of determining whether the examination interval of the carrier required by Article 1.15 could be extended. Article 1.03A authorizes the commissioner to adopt rules for general and uniform application for the conduct and execution of the duties and functions of the department. The Government Code, sec.sec.2001. 004-2001.038, authorize and require each state agency to adopt rules of practice setting forth the nature and requirements of available procedures and to prescribe procedures for adoption of rules by a state administrative agency. sec.7.84. Examination Frequency. (a) Definitions. The following words and terms, when used in this section, shall have the following meanings, unless the context clearly indicates otherwise. (1) Carrier-A domestic insurer subject to the examination frequency provided for in Insurance Code,Article 1.15. (2) Regular examination-The examination required by the Insurance Code, Article 1.15, sec.1. (b) Applicability. This section applies only to those carriers that have been incorporated or organized for more than three years and are due for a regular examination as of December 31, 1993, or later. (c) Deferment of regular examination. Annually, each carrier due for a regular examination to be conducted in the following year shall be reviewed by the associate commissioner for the Financial Program of the Texas Department of Insurance to determine whether the carrier's financial strength justifies a deferment of the regular examination. The commissioner may defer the regular examination of a carrier for one year if the carrier has undergone a regular examination within the preceding four years and the following conditions have been met at all times subsequent to that last regular examination: (1) the carrier's actuarial opinions required by the Insurance Code, Articles 1.11 and 3.28 were not adverse or qualified; (2) the carrier is subject to the requirements of the Insurance Code, Article 1.15A, or otherwise provides annually to the department an audit of its financial condition conducted by an independent certified public accountant, and the annual audits by its accountant did not indicate the existence of any material adverse financial conditions in the carrier; (3) the carrier has not been the subject of administrative or regulatory actions taken by the Texas Department of Insurance as provided by the Insurance Code, Articles 1.10A, 1.32, or 21.28-A, or similar actions taken by any other regulatory body; (4) all changes in control of the carrier have been properly approved by the Texas Department of Insurance as required by the Insurance Code, Article 21.49-1. (5) the carrier has the amount of minimum risk-based capital and surplus required by sec.7.401 of this title (relating to Minimum Risk-Based Capital and Surplus Requirements for Life, Accident and Health Insurers) or sec.7.410 of this title (relating to Minimum Risk-Based Capital and Surplus Requirements for Stock Property and Casualty Insurers), or meets the requirements of the Insurance Code, Article 2.20, sec.(f) (relating to Requirements for Non-stock Property and Casualty Insurers); (6) the carrier's unassigned funds (surplus) account is a positive balance; (7) the carrier has not experienced an operational (net) loss for any calendar year equal to or greater than 10% of its capital and surplus accounts at the beginning of such calendar year; (8) the carrier's capital and surplus accounts have not decreased 15% or more during any calendar year; (9) the carrier's investment in bonds designated as Class 3, 4, 5, or 6 by the Securities Valuation Office of the National Association of Insurance Commissioners is less than 200% of the carrier's capital and surplus accounts; (10) the carrier's net written accident and health insurance premiums (annualized) are less than 350% of its capital and surplus accounts; (11) the net written premiums (annualized) of a property and casualty carrier are less than 250% of its capital and surplus accounts; (12) the National Association of Insurance Commissioners has not deemed the carrier to be a priority one company; and (13) the carrier has not appeared as one of the top ten insurers on the complaint ratio listing maintained by the department at any time during the year of the annual review provided for in this subsection. (d) Nothing in this section shall be construed to limit the commissioner's authority to examine a carrier as frequently as the commissioner deems necessary. This agency hereby certifies that the rule as adopted has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority. Issued in Austin, Texas, on March 16, 1994. TRD-9437676 Linda K. von Quintus-Dorn Chief Clerk Texas Department of Insurance Effective date: April 6, 1994 Proposal publication date: December 21, 1993 For further information, please call: (512) 463-6327