Bill Text: TX HB4385 | 2021-2022 | 87th Legislature | Introduced
Bill Title: Relating to medical benefits under the workers' compensation system.
Spectrum: Partisan Bill (Republican 1-0)
Status: (Introduced - Dead) 2021-03-29 - Referred to Business & Industry [HB4385 Detail]
Download: Texas-2021-HB4385-Introduced.html
87R8037 KKR-F | ||
By: Patterson | H.B. No. 4385 |
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relating to medical benefits under the workers' compensation | ||
system. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. Section 1305.053, Insurance Code, is amended to | ||
read as follows: | ||
Sec. 1305.053. CONTENTS OF APPLICATION. Each certificate | ||
application must include: | ||
(1) a description or a copy of the applicant's basic | ||
organizational structure documents and other related documents, | ||
including organizational charts or lists that show: | ||
(A) the relationships and contracts between the | ||
applicant and any affiliates of the applicant; and | ||
(B) the internal organizational structure of the | ||
applicant's management and administrative staff; | ||
(2) biographical information regarding each person | ||
who governs or manages the affairs of the applicant, accompanied by | ||
information sufficient to allow the commissioner to determine the | ||
competence, fitness, and reputation of each officer or director of | ||
the applicant or other person having control of the applicant; | ||
(3) a copy of the form of any contract between the | ||
applicant and any provider or group of providers, and with any third | ||
party performing services on behalf of the applicant under | ||
Subchapter D; | ||
(4) a copy of the form of each contract with an | ||
insurance carrier, as described by Section 1305.154; | ||
(5) a financial statement, current as of the date of | ||
the application, that is prepared using generally accepted | ||
accounting practices and includes: | ||
(A) a balance sheet that reflects a solvent | ||
financial position; | ||
(B) an income statement; | ||
(C) a cash flow statement; and | ||
(D) the sources and uses of all funds; | ||
(6) a statement acknowledging that lawful process in a | ||
legal action or proceeding against the network on a cause of action | ||
arising in this state is valid if served in the manner provided by | ||
Chapter 804 for a domestic company; | ||
(7) a description and a map of the applicant's service | ||
area or areas, with key and scale, that identifies each county or | ||
part of a county to be served; | ||
(8) a description of programs and procedures to be | ||
utilized, including: | ||
(A) a complaint system, as required under | ||
Subchapter I; and | ||
(B) a quality improvement program, as required | ||
under Subchapter G; [ |
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(9) a list of all contracted network providers that | ||
demonstrates the adequacy of the network to provide comprehensive | ||
health care services sufficient to serve the population of injured | ||
employees within the service area and maps that demonstrate that | ||
the access and availability standards under Subchapter G are met; | ||
and | ||
(10) any other information that the commissioner | ||
requires by rule to implement this chapter. | ||
SECTION 2. Section 1305.154(c), Insurance Code, is amended | ||
to read as follows: | ||
(c) A network's contract with a carrier must include: | ||
(1) a description of the functions that the carrier | ||
delegates to the network, consistent with the requirements of | ||
Subsection (b), and the reporting requirements for each function; | ||
(2) a statement that the network and any management | ||
contractor or third party to which the network delegates a function | ||
will perform all delegated functions in full compliance with all | ||
requirements of this chapter, the Texas Workers' Compensation Act, | ||
and rules of the commissioner or the commissioner of workers' | ||
compensation; | ||
(3) a provision that the contract: | ||
(A) may not be terminated without cause by either | ||
party without 90 days' prior written notice; and | ||
(B) must be terminated immediately if cause | ||
exists; | ||
(4) a hold-harmless provision stating that the | ||
network, a management contractor, a third party to which the | ||
network delegates a function, and the network's contracted | ||
providers are prohibited from billing or attempting to collect any | ||
amounts from employees for health care services under any | ||
circumstances, including the insolvency of the carrier or the | ||
network, except as provided by Section 1305.451(b)(6); | ||
(5) a statement that the carrier retains ultimate | ||
responsibility for ensuring that all delegated functions and all | ||
management contractor functions are performed in accordance with | ||
applicable statutes and rules and that the contract may not be | ||
construed to limit in any way the carrier's responsibility, | ||
including financial responsibility, to comply with all statutory | ||
and regulatory requirements; | ||
(6) a statement that the network's role is to provide | ||
the services described under Subsection (b) as well as any other | ||
services or functions delegated by the carrier, including functions | ||
delegated to a management contractor, subject to the carrier's | ||
oversight and monitoring of the network's performance; | ||
(7) a requirement that the network provide the | ||
carrier, at least monthly and in a form usable for audit purposes, | ||
the data necessary for the carrier to comply with reporting | ||
requirements of the department and the division of workers' | ||
compensation with respect to any services provided under the | ||
contract, as determined by commissioner rules; | ||
(8) a requirement that the carrier, the network, any | ||
management contractor, and any third party to which the network | ||
delegates a function comply with the data reporting requirements of | ||
the Texas Workers' Compensation Act and rules of the commissioner | ||
of workers' compensation; | ||
(9) a contingency plan under which the carrier would, | ||
in the event of termination of the contract or a failure to perform, | ||
reassume one or more functions of the network under the contract, | ||
including functions related to: | ||
(A) payments to providers and notification to | ||
employees; | ||
(B) quality of care; and | ||
(C) [ |
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identifying and transitioning employees to new providers; | ||
(10) a provision that requires that any agreement by | ||
which the network delegates any function to a management contractor | ||
or any third party be in writing, and that such an agreement require | ||
the delegated third party or management contractor to be subject to | ||
all the requirements of this subchapter; | ||
(11) [ |
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[ |
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(A) any management contractor or third party to | ||
whom the network delegates a function must perform in compliance | ||
with this chapter and other applicable statutes and rules, and that | ||
the management contractor or third party is subject to the | ||
carrier's and the network's oversight and monitoring of its | ||
performance; and | ||
(B) if the management contractor or the third | ||
party fails to meet monitoring standards established to ensure that | ||
functions delegated to the management contractor or the third party | ||
under the delegation contract are in full compliance with all | ||
statutory and regulatory requirements, the carrier or the network | ||
may cancel the delegation of one or more delegated functions; | ||
(12) [ |
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management contractor or third party to which the network delegates | ||
a function provide all necessary information to allow the carrier | ||
to provide information to employees as required by Section | ||
1305.451; and | ||
(13) [ |
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contracting with a third party directly or through another third | ||
party, to require the third party to permit the commissioner to | ||
examine at any time any information the commissioner believes is | ||
relevant to the third party's financial condition or the ability of | ||
the network to meet the network's responsibilities in connection | ||
with any function the third party performs or has been delegated. | ||
SECTION 3. Section 1305.451(b), Insurance Code, is amended | ||
to read as follows: | ||
(b) The written description required under Subsection (a) | ||
must be in English, Spanish, and any additional language common to | ||
an employer's employees, must be in plain language and in a readable | ||
and understandable format, and must include, in a clear, complete, | ||
and accurate format: | ||
(1) a statement that the entity providing health care | ||
to employees is a workers' compensation health care network; | ||
(2) the network's toll-free number and address for | ||
obtaining additional information about the network, including | ||
information about network providers; | ||
(3) a statement that in the event of an injury, the | ||
employee must select a treating doctor: | ||
(A) from a list of all the network's treating | ||
doctors who have contracts with the network in that service area; or | ||
(B) as described by Section 1305.105; | ||
(4) a statement that, except for emergency services, | ||
the employee shall obtain all health care and specialist referrals | ||
through the employee's treating doctor; | ||
(5) an explanation that network providers have agreed | ||
to look only to the network or insurance carrier and not to | ||
employees for payment of providing health care, except as provided | ||
by Subdivision (6); | ||
(6) a statement that if the employee obtains health | ||
care from non-network providers without network approval, except as | ||
provided by Section 1305.006, the insurance carrier may not be | ||
liable, and the employee may be liable, for payment for that health | ||
care; | ||
(7) information about how to obtain emergency care | ||
services, including emergency care outside the service area, and | ||
after-hours care; | ||
(8) [ |
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[ |
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treatment in the event of the termination from the network of a | ||
treating doctor; | ||
(9) [ |
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system, including a statement that the network is prohibited from | ||
retaliating against: | ||
(A) an employee if the employee files a complaint | ||
against the network or appeals a decision of the network; or | ||
(B) a provider if the provider, on behalf of an | ||
employee, reasonably files a complaint against the network or | ||
appeals a decision of the network; | ||
(10) [ |
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network's procedures relating to adverse determinations and the | ||
availability of the independent review process; | ||
(11) [ |
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least quarterly, including: | ||
(A) the names and addresses of the providers; | ||
(B) a statement of limitations of accessibility | ||
and referrals to specialists; and | ||
(C) a disclosure of which providers are accepting | ||
new patients; and | ||
(12) [ |
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area. | ||
SECTION 4. Section 4201.054(a), Insurance Code, is amended | ||
to read as follows: | ||
(a) This [ |
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does not apply [ |
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service provided to a person eligible for workers' compensation | ||
medical benefits under Title 5, Labor Code. [ |
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SECTION 5. Section 408.0043(a), Labor Code, is amended to | ||
read as follows: | ||
(a) This section applies to a person, other than a | ||
chiropractor or a dentist, who performs health care services under | ||
this title as: | ||
(1) a doctor performing peer review; | ||
(2) [ |
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[ |
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health care service provided to an injured employee; | ||
[ |
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[ |
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(3) [ |
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quality review panel. | ||
SECTION 6. Section 408.0044(a), Labor Code, is amended to | ||
read as follows: | ||
(a) This section applies to a dentist who performs dental | ||
services under this title as: | ||
(1) a doctor performing peer review of dental | ||
services; or | ||
(2) [ |
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[ |
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dental service provided to an injured employee[ |
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[ |
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SECTION 7. Section 408.0045(a), Labor Code, is amended to | ||
read as follows: | ||
(a) This section applies to a chiropractor who performs | ||
chiropractic services under this title as: | ||
(1) a doctor performing peer review of chiropractic | ||
services; | ||
(2) [ |
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[ |
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chiropractic service provided to an injured employee; | ||
[ |
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[ |
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(3) [ |
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medical quality review panel. | ||
SECTION 8. Section 408.021(a), Labor Code, is amended to | ||
read as follows: | ||
(a) An employee who sustains a compensable injury is | ||
entitled to all health care reasonably required by the nature of the | ||
injury as and when needed as determined by the employee's treating | ||
doctor. The employee is specifically entitled to health care that: | ||
(1) cures or relieves the effects naturally resulting | ||
from the compensable injury; | ||
(2) promotes recovery; or | ||
(3) enhances the ability of the employee to return to | ||
or retain employment. | ||
SECTION 9. Sections 408.0231(b), (c), (e), and (f), Labor | ||
Code, are amended to read as follows: | ||
(b) The commissioner by rule shall establish criteria for: | ||
(1) deleting or suspending a doctor from the list of | ||
approved doctors; and | ||
(2) imposing sanctions on a doctor or an insurance | ||
carrier as provided by this section[ |
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(c) Rules adopted under Subsection (b) are in addition to, | ||
and do not affect, the rules adopted under Section 415.023(b). The | ||
criteria for deleting a doctor from the list or for recommending or | ||
imposing sanctions may include anything the commissioner considers | ||
relevant, including: | ||
(1) a sanction of the doctor by the commissioner for a | ||
violation of Chapter 413 or Chapter 415; | ||
(2) a sanction by the Medicare or Medicaid program | ||
for: | ||
(A) substandard medical care; | ||
(B) overcharging; | ||
(C) overutilization of medical services; or | ||
(D) any other substantive noncompliance with | ||
requirements of those programs regarding professional practice or | ||
billing; | ||
(3) evidence from the division's medical records that | ||
[ |
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evaluations, or impairment ratings are substantially different | ||
from those the commissioner finds to be fair and reasonable based on | ||
either a single determination or a pattern of practice; | ||
(4) a suspension or other relevant practice | ||
restriction of the doctor's license by an appropriate licensing | ||
authority; | ||
(5) professional failure to practice medicine or | ||
provide health care, including chiropractic care, in an acceptable | ||
manner consistent with the public health, safety, and welfare; | ||
(6) findings of fact and conclusions of law made by a | ||
court, an administrative law judge of the State Office of | ||
Administrative Hearings, or a licensing or regulatory authority; or | ||
(7) a criminal conviction. | ||
(e) The commissioner shall act on a recommendation by the | ||
medical advisor selected under Section 413.0511 and, after notice | ||
and the opportunity for a hearing, may impose sanctions under this | ||
section on a doctor or an insurance carrier [ |
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commissioner of insurance shall enter into a memorandum of | ||
understanding to coordinate the regulation of insurance carriers | ||
[ |
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[ |
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(f) The sanctions the commissioner may recommend or impose | ||
under this section include: | ||
(1) reduction of allowable reimbursement; | ||
(2) mandatory preauthorization of all or certain | ||
health care services; | ||
(3) required peer review monitoring, reporting, and | ||
audit; | ||
(4) deletion or suspension from the approved doctor | ||
list [ |
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(5) restrictions on appointment under this chapter; | ||
(6) conditions or restrictions on an insurance carrier | ||
regarding actions by insurance carriers under this subtitle in | ||
accordance with the memorandum of understanding adopted under | ||
Subsection (e); and | ||
(7) mandatory participation in training classes or | ||
other courses as established or certified by the division. | ||
SECTION 10. Section 408.122, Labor Code, is amended to read | ||
as follows: | ||
Sec. 408.122. ELIGIBILITY FOR IMPAIRMENT INCOME BENEFITS. | ||
A claimant may not recover impairment income benefits unless | ||
evidence of impairment based on an objective clinical or laboratory | ||
finding exists. A [ |
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claimant's treating doctor is presumed to be accurate [ |
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SECTION 11. Section 409.0091(e), Labor Code, is amended to | ||
read as follows: | ||
(e) It is not a defense to a subclaim by a health care | ||
insurer that: | ||
(1) the subclaimant has not sought reimbursement from | ||
a health care provider or the subclaimant's insured; or | ||
(2) [ |
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[ |
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workers' compensation insurance carrier, as provided by Section | ||
408.027, before the 95th day after the date the health care for | ||
which the subclaimant paid was provided. | ||
SECTION 12. Section 410.307(b), Labor Code, is amended to | ||
read as follows: | ||
(b) If substantial change of condition is disputed, the | ||
court shall require the employee's treating [ |
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the case to verify the substantial change of condition, if any. The | ||
findings of the treating [ |
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be correct, and the court shall base its finding on the medical | ||
evidence presented by the treating [ |
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substantial change of condition unless the preponderance of the | ||
other medical evidence is to the contrary. | ||
SECTION 13. Section 413.002(b), Labor Code, is amended to | ||
read as follows: | ||
(b) In monitoring [ |
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organizations who provide services described by this chapter, the | ||
division shall evaluate: | ||
(1) compliance with this subtitle and with rules | ||
adopted by the commissioner relating to medical policies, fee | ||
guidelines, treatment guidelines, return-to-work guidelines, and | ||
impairment ratings; and | ||
(2) the quality and timeliness of decisions made under | ||
Section [ |
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SECTION 14. Section 413.017, Labor Code, is amended to read | ||
as follows: | ||
Sec. 413.017. PRESUMPTION OF REASONABLENESS. Medical [ |
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presumed to be reasonable[ |
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[ |
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SECTION 15. Sections 413.031(a), (e), (e-1), and (h), Labor | ||
Code, are amended to read as follows: | ||
(a) A party, including a health care provider, is entitled | ||
to a review of a medical service provided or for which authorization | ||
of payment is sought if a health care provider is: | ||
(1) denied payment or paid a reduced amount for the | ||
medical service rendered; | ||
(2) [ |
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[ |
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received; or | ||
(3) [ |
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or reduced for a medical service rendered. | ||
(e) Except as provided by Subsection [ |
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(f), [ |
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service provided under this chapter or Chapter 408 shall be | ||
conducted by an independent review organization under Chapter 4202, | ||
Insurance Code, in the same manner as reviews of utilization review | ||
decisions by health maintenance organizations. It is a defense for | ||
the insurance carrier if the carrier timely complies with the | ||
decision of the independent review organization. | ||
(e-1) In performing a review of medical necessity under | ||
Subsection [ |
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consider the division's health care reimbursement policies and | ||
guidelines adopted under Section 413.011. If the independent review | ||
organization's decision is contrary to the division's policies or | ||
guidelines adopted under Section 413.011, the independent review | ||
organization must indicate in the decision the specific basis for | ||
its divergence in the review of medical necessity. | ||
(h) The insurance carrier shall pay the cost of the review | ||
if the dispute arises in connection with[ |
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[ |
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commissioner rules under that section. | ||
SECTION 16. Section 413.0511(b), Labor Code, is amended to | ||
read as follows: | ||
(b) The medical advisor shall make recommendations | ||
regarding the adoption of rules and policies to: | ||
(1) develop, maintain, and review guidelines as | ||
provided by Section 413.011, including rules regarding impairment | ||
ratings; | ||
(2) review compliance with those guidelines; | ||
(3) regulate or perform other acts related to medical | ||
benefits as required by the commissioner; | ||
(4) impose sanctions or delete doctors from the | ||
division's list of approved doctors under Section 408.023 for: | ||
(A) any reason described by Section 408.0231; or | ||
(B) noncompliance with commissioner rules; | ||
(5) impose conditions or restrictions as authorized by | ||
Section 408.0231(f); | ||
(6) receive, and share with the medical quality review | ||
panel established under Section 413.0512, confidential | ||
information, and other information to which access is otherwise | ||
restricted by law, as provided by Sections 413.0512, 413.0513, and | ||
413.0514 from the Texas State Board of Medical Examiners, the Texas | ||
Board of Chiropractic Examiners, or other occupational licensing | ||
boards regarding a physician, chiropractor, or other type of doctor | ||
who applies for registration or is registered with the division on | ||
the list of approved doctors; | ||
(7) determine minimal modifications to the | ||
reimbursement methodology and model used by the Medicare system as | ||
necessary to meet occupational injury requirements; and | ||
(8) monitor the quality and timeliness of decisions | ||
made by [ |
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and the imposition of sanctions regarding those decisions. | ||
SECTION 17. Sections 413.0512(b) and (c), Labor Code, are | ||
amended to read as follows: | ||
(b) The agencies that regulate health professionals who are | ||
licensed or otherwise authorized to practice a health profession | ||
under Title 3, Occupations Code, and who are involved in the | ||
provision of health care as part of the workers' compensation | ||
system in this state shall develop lists of health care providers | ||
licensed or otherwise regulated by those agencies who have | ||
demonstrated experience in workers' compensation [ |
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members of the medical quality review panel from the names on those | ||
lists and, when appointing members of the medical quality review | ||
panel, shall select specialists from various health care specialty | ||
fields to serve on the panel to ensure that the membership of the | ||
panel has expertise in a wide variety of health care specialty | ||
fields. The medical advisor shall also consider nominations for the | ||
panel made by labor, business, and insurance organizations. | ||
(c) The medical quality review panel shall recommend to the | ||
medical advisor: | ||
(1) appropriate action regarding doctors, other | ||
health care providers, insurance carriers, [ |
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(2) the addition or deletion of doctors from the list | ||
of approved doctors under Section 408.023[ |
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[ |
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SECTION 18. Section 413.054(a), Labor Code, is amended to | ||
read as follows: | ||
(a) A person who performs services for the division as [ |
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performing a medical case review, or a member of a peer review panel | ||
has the same immunity from liability as the commissioner under | ||
Section 402.00123. | ||
SECTION 19. Section 415.0035(a), Labor Code, is amended to | ||
read as follows: | ||
(a) An insurance carrier or its representative commits an | ||
administrative violation if that person: | ||
(1) fails to submit to the division a settlement or | ||
agreement of the parties; or | ||
(2) fails to timely notify the division of the | ||
termination or reduction of benefits and the reason for that | ||
action[ |
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[ |
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SECTION 20. Sections 504.053(c) and (d), Labor Code, are | ||
amended to read as follows: | ||
(c) If the political subdivision or pool provides medical | ||
benefits in the manner authorized under Subsection (b)(2), the | ||
following do not apply: | ||
(1) [ |
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[ |
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408.021; | ||
(2) [ |
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(3) [ |
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Sections 1305.501, 1305.502, and 1305.503. | ||
(d) If the political subdivision or pool provides medical | ||
benefits in the manner authorized under Subsection (b)(2), the | ||
following standards apply: | ||
(1) the political subdivision or pool must ensure that | ||
workers' compensation medical benefits are reasonably available to | ||
all injured workers of the political subdivision or the injured | ||
workers of the members of the pool within a designed service area; | ||
(2) the political subdivision or pool must ensure that | ||
all necessary health care services are provided in a manner that | ||
will ensure the availability of and accessibility to adequate | ||
health care providers, specialty care, and facilities; | ||
(3) the political subdivision or pool must have an | ||
internal review process for resolving complaints relating to the | ||
manner of providing medical benefits, including an appeal to the | ||
governing body or its designee and appeal to an independent review | ||
organization; | ||
(4) the political subdivision or pool must establish | ||
reasonable procedures for the transition of injured workers to | ||
contract providers and for the continuity of treatment, including | ||
notice of impending termination of providers and a current list of | ||
contract providers; | ||
(5) the political subdivision or pool shall provide | ||
for emergency care if an injured worker cannot reasonably reach a | ||
contract provider and the care is for medical screening or other | ||
evaluation that is necessary to determine whether a medical | ||
emergency condition exists, necessary emergency care services | ||
including treatment and stabilization, and services originating in | ||
a hospital emergency facility following treatment or stabilization | ||
of an emergency medical condition; | ||
(6) [ |
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[ |
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to report data to the appropriate agency as required by Title 5 of | ||
this code and Chapter 1305, Insurance Code; and | ||
(7) [ |
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to the requirements under Sections 1305.501, 1305.502, and | ||
1305.503, Insurance Code. | ||
SECTION 21. Section 504.055(b), Labor Code, is amended to | ||
read as follows: | ||
(b) This section applies only to a first responder who | ||
sustains a [ |
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Penal Code, in the course and scope of employment that prevents the | ||
first responder from performing the full duties assigned to the | ||
first responder at the time of the injury. For purposes of this | ||
section, an injury sustained in the course and scope of employment | ||
includes an injury sustained by a first responder providing | ||
services on a volunteer basis. | ||
SECTION 22. The following provisions are repealed: | ||
(1) Sections 1305.004(a)(19), (27), (28), and (29), | ||
Insurance Code; | ||
(2) Section 1305.101(b), Insurance Code; | ||
(3) Section 1305.153(b), Insurance Code; | ||
(4) Subchapter H, Chapter 1305, Insurance Code; | ||
(5) Section 4201.054(b), Insurance Code; | ||
(6) Sections 401.011(22-a), (38-a), (42-a), and | ||
(42-b), Labor Code; | ||
(7) Section 408.004, Labor Code; | ||
(8) Section 408.0041, Labor Code; | ||
(9) Section 408.0042, Labor Code; | ||
(10) Section 408.1225, Labor Code; | ||
(11) Section 408.125, Labor Code; | ||
(12) Section 408.151, Labor Code; | ||
(13) Section 409.0091(d), Labor Code; | ||
(14) Section 413.014, Labor Code; | ||
(15) Sections 413.031(d), (g), and (m), Labor Code; | ||
and | ||
(16) Section 413.044, Labor Code. | ||
SECTION 23. The change in law made by this Act applies only | ||
to a claim for workers' compensation benefits based on a | ||
compensable injury that occurs on or after the effective date of | ||
this Act. A claim based on a compensable injury that occurs before | ||
the effective date of this Act is governed by the law in effect on | ||
the date the compensable injury occurred, and the former law is | ||
continued in effect for that purpose. | ||
SECTION 24. This Act takes effect September 1, 2021. |