Amend HB 2600 by striking all below the enacting clause and
substituting the following:
ARTICLE 1. APPROVED DOCTORS; MEDICAL REVIEW
SECTION 1.01. Subchapter B, Chapter 408, Labor Code, is
amended by amending Section 408.023 and adding Section 408.0231 to
read as follows:
Sec. 408.023. LIST OF APPROVED DOCTORS; DUTIES OF TREATING
DOCTORS. (a) The commission shall develop a list of doctors
licensed in this state who are approved to provide health care
services under this subtitle. Each doctor licensed in this state
on September 1, 2001 <January 1, 1993>, is eligible to be included
on the commission's list of approved doctors if the doctor:
(1) registers with the commission in the manner
prescribed by commission rules; and
(2) complies with the requirements adopted by the
commission under this section.
(b) The commission by rule shall establish reasonable
requirements for doctors and health care providers financially
related to those doctors regarding training, impairment rating
testing, and disclosure of financial interests as required by
Section 413.041, and for monitoring of those doctors and health
care providers as provided by Sections 408.0231 and 413.0512. The
commission by rule shall provide a reasonable period, not to exceed
18 months after the adoption of rules under this section, for
doctors to comply with the registration and training requirements
of this subchapter. Except as otherwise provided by this section,
the requirements under this subsection apply to doctors and other
health care providers who:
(1) provide health care services as treating doctors;
(2) provide health care services as authorized by this
chapter;
(3) perform medical peer review under this subtitle;
(4) perform utilization review of medical benefits
provided under this subtitle; or
(5) provide health care services on referral from a
treating doctor, as provided by commission rule.
(c) The commission shall issue to a doctor who is approved
by the commission a certificate of registration. In determining
whether to issue a certificate of registration, the commission may
consider and condition its approval on any practice restrictions
applicable to the applicant that are relevant to services provided
under this subtitle. The commission may also consider the practice
restrictions of an applicant when determining appropriate sanctions
under Section 408.0231.
(d) A certificate of registration issued under this section
is valid, unless revoked, suspended, or revised, for the period
provided by commission rule and may be renewed on application to
the commission. The commission shall provide notice to each
doctor on the approved doctor list of the pending expiration of the
doctor's certificate of registration not later than the 60th day
before the date of expiration of the certificate <unless
subsequently deleted and not reinstated. The name of a doctor
shall be placed on the list of approved doctors when that doctor
becomes licensed in this state>.
(e) Notwithstanding other provisions of this section, a <A>
doctor not licensed in this state but licensed in another state or
jurisdiction who treats employees or performs utilization review of
health care for an insurance carrier may apply for a certificate of
registration under this section <to the commission> to be included
on the commission's list of approved doctors.
(f) Except in an emergency or for immediate post-injury
medical care as defined by commission rule, or as provided by
Subsection (h) or (i), each doctor who performs functions under
this subtitle, including examinations under this chapter, must hold
a certificate of registration and be on the list of approved
doctors in order to perform services or receive payment for those
services.
(g) The commission by rule shall modify registration and
training requirements for doctors who infrequently provide health
care, who perform utilization review or peer review functions for
insurance carriers, or who participate in regional networks
established under this subchapter, as necessary to ensure that
those doctors are informed of the regulations that affect health
care benefit delivery under this subtitle.
(h) Notwithstanding Section 4(h), Article 21.58A, Insurance
Code, a utilization review agent that uses doctors to perform
reviews of health care services provided under this subtitle may
use doctors licensed by another state to perform the reviews, but
the reviews must be performed under the direction of a doctor
licensed to practice in this state.
(i) The commission may grant exceptions to the requirement
imposed under Subsection (f) as necessary to ensure that:
(1) employees have access to health care; and
(2) insurance carriers have access to evaluations of
an employee's health care and income benefit eligibility as
provided by this subtitle.
(j) The injured employee's treating doctor is responsible
for the efficient management of medical care as required by Section
408.025(c) and commission rules. The commission shall collect
information regarding:
(1) return-to-work outcomes;
(2) patient satisfaction; and
(3) cost and utilization of health care provided or
authorized by a treating doctor on the list of approved doctors.
(k) The commission may adopt rules to define the role of the
treating doctor and to specify outcome information to be collected
for a treating doctor.
Sec. 408.0231. MAINTENANCE OF LIST OF APPROVED DOCTORS;
SANCTIONS AND PRIVILEGES RELATING TO HEALTH CARE. (a) The
executive director shall delete from the list of approved doctors a
doctor:
(1) who fails to register with the commission as
provided by this chapter and commission rules;
(2) who is deceased;
(3) whose license to practice in this state is
revoked, suspended, or not renewed by the appropriate licensing
authority; or
(4) who requests to be removed from the list.
(b) The commission by rule shall establish criteria for:
(1) deleting or suspending a doctor from the list of
approved doctors;
(2) imposing sanctions on a doctor or an insurance
carrier as provided by this section;
(3) monitoring of utilization review agents, as
provided by a memorandum of understanding between the commission
and the Texas Department of Insurance; and
(4) authorizing increased or reduced utilization
review and preauthorization controls on a doctor.
(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 commission considers
relevant, including:
(1) a sanction <sanctions> of the doctor by the
commission for a violation <violations> of Chapter 413 or Chapter
415;
(2) a sanction <sanctions> by the Medicare or Medicaid
program for:
(A) substandard medical care;
(B) overcharging; <or>
(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 commission's medical records
that the applicable insurance carrier's utilization review
practices or the doctor's charges, fees, diagnoses, <or>
treatments, evaluations, or impairment ratings are substantially
different from those the commission finds to be fair and reasonable
based on either a single determination or a pattern of practice;
<and>
(4) a suspension or other relevant practice
restriction of the doctor's license by an <the> 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.
(d) <(c)> The commission by rule shall establish procedures
under which <for> a doctor may <to> apply for:
(1) reinstatement to the list of approved doctors; or
(2) restoration of doctor practice privileges removed
by the commission based on sanctions imposed under this section.
(e) The commission 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 or may recommend action
regarding a utilization review agent. The commission and the Texas
Department of Insurance shall enter into a memorandum of
understanding to coordinate the regulation of insurance carriers
and utilization review agents as necessary to ensure:
(1) compliance with applicable regulations; and
(2) that appropriate health care decisions are reached
under this subtitle and under Article 21.58A, Insurance Code.
(f) The sanctions the commission 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 and the designated doctor list;
(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 between the
commission and the Texas Department of Insurance regarding Article
21.58A, Insurance Code; and
(7) mandatory participation in training classes or
other courses as established or certified by the commission.
SECTION 1.02. Subchapter E, Chapter 413, Labor Code, is
amended by amending Section 413.051 and adding Sections 413.0511,
413.0512, and 413.0513 to read as follows:
Sec. 413.051. CONTRACTS WITH REVIEW ORGANIZATIONS AND HEALTH
CARE PROVIDERS. (a) The commission may contract with a health care
provider, health care provider professional review organization, or
other entity to develop, maintain, or review medical policies or
fee guidelines or to review compliance with the medical policies or
fee guidelines.
(b) For purposes of review or resolution of a dispute as to
compliance with the medical policies or fee guidelines, the
commission may contract <only> with a health care provider, health
care provider professional review organization, or other entity
that includes in the review process health care practitioners who
are licensed in the category under review and are of the same field
or specialty as the category under review.
(c) The commission may contract with a health care provider,
health care provider professional review organization, or other
entity for medical consultant services, including:
(1) independent medical examinations;
(2) medical case reviews; or
(3) establishment of medical policies and fee
guidelines.
(d) The commission shall establish standards for contracts
under this section.
(e) For purposes of this section, "health care provider
professional review organization" includes an independent review
organization.
Sec. 413.0511. MEDICAL ADVISOR. (a) The commission shall
employ or contract with a medical advisor, who must be a doctor as
that term is defined by Section 401.011.
(b) The medical advisor shall make recommendations regarding
the adoption of rules 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 commission;
(4) impose sanctions or delete doctors from the
commission's list of approved doctors under Section 408.023 for:
(A) any reason described by Section 408.0231; or
(B) noncompliance with commission 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
from the Texas State Board of Medical Examiners, the Texas Board of
Chiropractic Examiners, or other occupational licensing boards
regarding disciplinary actions imposed on a physician,
chiropractor, or other type of doctor who applies for registration
or is registered with the commission on the list of approved
doctors; and
(7) determine minimal modifications to the
reimbursement methodology and model used by the Medicare system as
necessary to meet occupational injury requirements.
Sec. 413.0512. MEDICAL QUALITY REVIEW PANEL. (a) The
medical advisor shall establish a medical quality review panel of
health care providers to assist the medical advisor in performing
the duties required under Section 413.0511. The panel is
independent of the medical advisory committee created under Section
413.005 and is not subject to Chapter 2110, Government Code.
(b) The Texas State Board of Medical Examiners and the Texas
Board of Chiropractic Examiners, with input from their respective
professional associations, shall develop lists of physicians and
chiropractors licensed by those agencies who have demonstrated
experience in workers' compensation or utilization review. The
medical advisor shall consider appointing some of the members of
the medical quality review panel from the names on those lists.
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, and utilization review agents;
and
(2) the addition or deletion of doctors from the list
of approved doctors under Section 408.023 or the list of designated
doctors established under Section 408.122.
(d) A person who serves on the medical quality review panel
is not liable in a civil action for an act performed in good faith
as a member of the panel and is entitled to the same protections
afforded a commission member under Section 402.010.
(e) The actions of a person serving on the medical quality
review panel do not constitute utilization review and are not
subject to Article 21.58A, Insurance Code.
Sec. 413.0513. CONFIDENTIALITY REQUIREMENTS. (a) Information
maintained by or on behalf of the commission under Section 413.0511
or 413.0512, and that is confidential under law, may not be
disclosed under Section 413.0511 or 413.0512 except:
(1) in a criminal proceeding;
(2) in a hearing conducted by or on behalf of the
commission;
(3) in a hearing conducted by another licensing or
regulatory authority, as provided in the interagency agreement; or
(4) on a finding of good cause in an administrative or
judicial proceeding involving the enforcement of this subtitle or
in a disciplinary action under this subtitle.
(b) Confidential information developed by or on behalf of
the commission under Section 413.0512 is not subject to discovery
or court subpoena in any action other than:
(1) an action to enforce this subtitle brought by the
commission, an appropriate licensing or regulatory agency, or an
appropriate enforcement authority; or
(2) a criminal proceeding.
SECTION 1.03. (a) The Texas Workers' Compensation Commission
shall adopt rules as required by Chapter 408, Labor Code, as
amended by this article, not later than February 1, 2002.
(b) A doctor is not required to hold a certificate of
registration issued under Section 408.023, Labor Code, as amended
by this article, to perform medical services under Subtitle A,
Title 5, Labor Code, before the date provided by commission rules
adopted to implement that section.
ARTICLE 2. MEDICAL NETWORK PARTICIPATION OPTION
SECTION 2.01. Subchapter B, Chapter 408, Labor Code, is
amended by adding Sections 408.0221, 408.0222, and 408.0223 to read
as follows:
Sec. 408.0221. REGIONAL HEALTH CARE DELIVERY NETWORKS;
ADVISORY COMMITTEE. (a) In this section:
(1) "Advisory committee" means the Health Care Network
Advisory Committee.
(2) "Regional network" means a regional workers'
compensation health care delivery network established by the
commission under this section.
(b) The regional networks established under this section
shall be fee-for-service networks designed to improve the quality
and reduce the cost of health care, with active health care
management and monitoring and a full range of health care services
under contract as considered feasible under the feasibility study
required under Subsection (d).
(c) The Health Care Network Advisory Committee is
established to advise the commission on the implementation of this
section and Section 408.0222. Members of the advisory committee
are appointed by the governor for staggered two-year terms, with
the membership as follows:
(1) three employee representatives recommended by a
recognized statewide labor federation;
(2) three employer representatives;
(3) three ex officio insurance carrier
representatives, with one member representing state agencies, one
member representing the Texas Workers' Compensation Insurance Fund,
and one member representing a voluntary market insurance carrier;
(4) three ex officio health care provider
representatives; and
(5) the commission's medical advisor, who shall serve
as chair of the advisory committee.
(d) The commission, on behalf of the advisory committee
established under this section, shall establish and, through
competitive procurement, contract with regional networks for the
provision of health care under this subtitle. The commission
shall, through competitive procurement, contract with one or more
entities to determine the feasibility of, develop, and evaluate the
regional networks established under this section. Those entities
shall also recommend to the advisory committee appropriate network
standards and application requirements and assist the advisory
committee during the procurement process.
(e) The advisory committee shall make recommendations to the
commission regarding:
(1) the development of the standards by which health
care services are provided through regional networks;
(2) regional network application requirements and
fees;
(3) contract proposals;
(4) the feasibility of establishing one or more
regional networks using a phased implementation and evaluation
process;
(5) the use of consultants as necessary to assist the
commission in the procurement of regional network contracts; and
(6) the selection of administrators to build and
manage the regional networks and to report on their progress.
(f) The advisory committee shall gather information from
other entities, including the Research and Oversight Council on
Workers' Compensation, the Texas Health Care Information Council,
the Texas Department of Insurance, the Texas Department of Health,
and the Employees Retirement System of Texas.
(g) The standards adopted for preferred provider networks
under Article 3.70-3C, Insurance Code, as added by Chapter 1024,
Acts of the 75th Legislature, Regular Session, 1997, apply as
minimum standards for regional health care delivery networks
created under this section and are adopted by reference in this
section except to the extent they are inconsistent with this
subtitle. The advisory committee may also recommend additional
standards, including standards that require:
(1) for each geographic region, access to an adequate
number of health care providers and treating doctors in each
appropriate health care discipline and the professional specialties
within those disciplines and a viable network through:
(A) the use of economic profiling as described
by Article 3.70-3C, Insurance Code, as added by Chapter 1024, Acts
of the 75th Legislature, Regular Session, 1997; and
(B) limitations on the number of providers, as
provided by that article;
(2) the ability of an employee to receive treatment by
a regional network provider within a reasonable amount of time of
the regional network's knowledge of the need or request for
treatment and within a reasonable travel distance for the employee;
(3) a reasonable effort by the regional network to
attract health care providers who reflect the ethnic and cultural
background of the regional employee population;
(4) the availability of board-certified occupational
medicine specialists to provide expertise on disability management
and prevention and treatment of occupational injuries and
illnesses;
(5) accreditation of the regional networks or a
commitment to seek accreditation from a nationally recognized
organization such as the American Accreditation HealthCare
Commission or the National Committee for Quality Assurance;
(6) the use of strict credentialing criteria by
regional networks in the selection and deselection of its health
care providers, including verification that the provider:
(A) is on the commission's list of approved
doctors, if the provider is required to be on that list;
(B) has not, at the time of selection or
deselection, been sanctioned or made subject to additional
utilization review requirements by the commission;
(C) is not, at the time of selection or
deselection, subject to sanctions or substantive practice
restrictions imposed by the provider's licensing authority;
(D) has or is able to obtain practice
privileges, if required, at a participating hospital; and
(E) is covered by professional liability
insurance coverage as required by the regional network contract;
(7) satisfactory evidence of the regional network's
ability to comply with any financial requirements and ensure
delivery of services;
(8) compliance with ongoing training and educational
requirements established by the commission;
(9) the use of nationally recognized, scientifically
valid, and outcome-based treatment standards as guidelines for
health care;
(10) disclosure of the availability of interpreter
services as appropriate for the evaluation and treatment of
employees;
(11) timely and accurate reporting of data to
appropriately manage and determine the effectiveness of the
regional network in reducing medical costs and ensuring quality of
care;
(12) a process for reconsideration of medical
necessity denials and dispute resolution within the regional
network; and
(13) a process for reviewing requests for a change in
treating doctors made under Section 408.0222(s).
(h) The advisory committee and the Research and Oversight
Council on Workers' Compensation shall develop evaluation standards
and specifications as necessary to implement a regional network
report card. The commission shall ensure that the report card is
published and available for inspection. The commission may procure
services as necessary to produce the report card. The report card,
at a minimum, must be based on contracted reviews and must include
a risk-adjusted evaluation of:
(1) employee access to care;
(2) coordination of care and return to work;
(3) communication among system participants;
(4) return-to-work outcomes;
(5) health-related outcomes;
(6) employee, health care provider, employer, and
insurance carrier satisfaction;
(7) disability and re-injury prevention;
(8) appropriate clinical care;
(9) health care costs;
(10) utilization of health care; and
(11) statistical outcomes of medical dispute
resolution provided by independent review organizations.
(i) The regional network administrators shall report
quarterly to the commission and the advisory committee on the
progress of implementing the regional networks and shall submit
consolidated annual reports. The Research and Oversight Council on
Workers' Compensation shall report to the legislature by January 1
of each odd-numbered year on the status of the implementation of
regional networks under this section.
(j) The commission shall ensure that regional network
contracts provide that insurance carriers have reasonable rights to
conduct audits under this subsection. Insurance carriers
participating in the regional network shall be allowed the
opportunity for consolidated audits of the regional networks.
(k) The cost of assessing the feasibility of, developing,
and evaluating the regional networks created under this section
shall be funded through an assessment on the subsequent injury fund
established under Section 403.006. This cost may not exceed a
total of $1.5 million for the regional networks. The cost of
ongoing regional network administration and management services
shall be included in the fees for health care services paid by
insurance carriers participating in the regional network.
Sec. 408.0222. PARTICIPATION IN REGIONAL NETWORK; SELECTION
OF DOCTOR WITHIN REGIONAL NETWORK; BENEFIT INCENTIVES. (a) An
insurance carrier or a self-insurer certified to provide workers'
compensation coverage in this state may elect to participate or not
participate, by contract, in a regional network established under
Section 408.0221. A public employer covered under Subtitle C of
this title, other than an employer covered under Chapter 504, is
required to participate in a regional network established under
Section 408.0221. An insurance carrier who elects to participate
in regional networks agrees to abide by the terms of the regional
network contracts between the commission and the regional networks.
(b) An insurance carrier may limit its election to
participate in a regional network established under Section
408.0221 to a particular employer or a particular region of this
state. This subsection expires January 1, 2006.
(c) A health care provider participating in a regional
network established under Section 408.0221 may perform only those
procedures that are within the scope of the practice for which the
health care provider is licensed.
(d) An employee may elect to participate or not participate
in a regional network established under Section 408.0221. Only an
employee covered by an insurance carrier who has elected to
participate in a regional network established under Section
408.0221 may elect to participate in that regional network. An
eligible employee may elect to participate or not participate in
the regional network for each compensable injury sustained by the
employee. Except as provided by this section, the employee's
election to participate in the network is effective for all medical
care related to that injury. The advisory committee shall make
recommendations and the commission, by rule, shall establish:
(1) the form and manner by which an employee:
(A) receives notice of the employee's rights; or
(B) documents the employee's election or
rescission of a prior election;
(2) the timing and recovery of a payment of enhanced
benefits; and
(3) other related issues.
(e) Except as provided by Subsection (f), an employee shall
make the election described by this section during an
employer-designated enrollment period or at the time of employment.
An employee who has elected to participate in the network may
rescind that election at any time before the earlier of:
(1) the date on which the employee begins to receive
enhanced income benefits under Subsection (m); or
(2) the 14th day after the date on which the employee
receives health care from a network health care provider.
(f) An employee may elect to participate in a regional
network established under Section 408.0221 at any time with the
insurance carrier's agreement. An employee is not bound by an
election to participate in a regional network made under
Subsection (d) or this subsection if:
(1) the insurance carrier waives the election;
(2) the commission invalidates the election based on a
determination of coercion;
(3) the employee relocates to an area outside of the
regional network's service area, and the regional network is not
able to identify alternate network providers to provide health care
services reasonable for the employee's medical condition; or
(4) notwithstanding Subsection (n), the commission
sets aside the employee's election based on a finding that:
(A) the worker was bound by an election to
participate in the network;
(B) the carrier disputes the compensability of
the employee's injury; and
(C) network health care providers are unwilling
to provide health care to the employee pending the resolution of
the dispute.
(g) An insurance carrier who elects to participate in a
regional network established under Section 408.0221 shall provide
each employer who obtains coverage through the insurance carrier
with adequate information about the regional network to share with
the employer's employees. Before an employee makes an election
under this section to participate in a regional network, the
employer shall provide the employee with:
(1) a complete, plain-language description of the
regional network's services, restrictions, and benefits, including
a description of the enhanced income benefits that may be due; and
(2) access to the most recent:
(A) list of doctors available through the
regional network; and
(B) regional network report card developed under
Section 408.0221.
(h) An employer shall not discharge, subject to disciplinary
action, or take an adverse employment action against an employee
who elects not to participate in a regional network created under
Section 408.0221 if the employer's action would not have occurred
in the absence of the employee's election not to participate.
(i) An employee may bring suit against an employer for
violation of Subsection (h) if:
(1) the employee gives written notice of intent to
bring suit to the employer within 60 days of the alleged violation;
and
(2) the employer does not reinstate the employee and
pay actual wages lost and reasonable attorney's fees incurred due
to the employer's action within 60 days of notification of the
employee's intent to bring suit.
(j) The employee must bring suit for an employer's violation
of Subsection (h) within 120 days of the alleged violation. A suit
under this section may be brought in the county in which:
(1) the plaintiff resides;
(2) the plaintiff was employed; or
(3) the defendant's primary place of business is
located.
(k) If the employee prevails in an action under Subsection
(i), the employee may recover:
(1) lost wages;
(2) reinstatement of front pay as equitable relief in
lieu of reinstatement;
(3) reasonable attorney's fees; and
(4) court costs.
(l) A suit under this section is the exclusive remedy for
violation of Subsection (h), and the provisions of Chapter 451 do
not apply to such a violation. Parties may not maintain an action
under Rule 42, Texas Rules of Civil Procedure.
(m) An employee who elects to participate in a regional
network created under Section 408.0221 shall receive:
(1) notwithstanding Section 408.082(c), income
benefits from the date disability begins if the disability lasts
two weeks or longer; and
(2) notwithstanding Section 408.061, an increased
maximum weekly benefit of up to 150 percent of the state average
weekly wage for temporary income benefits.
(n) Except for emergency care, or as otherwise provided by
this section, an employee who elects to participate in a regional
network shall receive medical treatment, including referrals, from
health care providers within the regional network. An employee or
an employee's treating doctor may use a health care provider
outside of the regional network with the approval of the regional
network for good cause consistent with the regional network
contract. If medically necessary services are not available
through regional network health care providers, the regional
network must, on the request of a regional network health care
provider, within a reasonable time allow a referral to a
nonregional network health care provider and shall fully reimburse
the nonregional network physician or provider at the rate provided
by the commission fee guidelines or an agreed rate. For purposes of
this subsection, "emergency care" has the meaning assigned by
Section 2(g), Texas Health Maintenance Organization Act (Article
20A.02, Vernon's Texas Insurance Code).
(o) A health care provider who participates in a regional
network created under Section 408.0221 shall be reimbursed and be
subject to utilization review as provided by the regional network
contract. The insurance carrier is responsible for payment of
regional network providers as provided by the contract with the
regional network. A non-network provider who does not obtain the
approval of the regional network to provide services may not be
reimbursed by the insurance carrier, unless the provider requested
and received verification from the insurance carrier that the
employee was not bound by a network election under Subsection (e).
(p) To resolve an issue regarding the necessity or the
appropriateness of care, or referrals to nonregional network
physicians or providers, an employee or an employee's treating
doctor may request a review by an independent review organization
under Section 413.031(d).
(q) An employee who elects to participate in a regional
network established under Section 408.0221 shall select an initial
treating doctor within the regional network as provided by the
regional network contract. An employee who requests to change
treating doctors within the regional network is not subject to
Section 408.022. At the sole discretion of the regional network,
an employee may select a treating doctor outside of the regional
network if:
(1) the employee has a preexisting relationship with a
doctor who maintains the employee's medical records and has a
documented history of treatment before the date of injury; and
(2) that doctor agrees in writing to abide by the
rules, terms, and conditions of the regional network contract,
including an agreement to refer the employee within the regional
network for services available through the regional network.
(r) An employee is subject to the selection of doctor,
change of doctor, and other medical benefit and income benefit
requirements established under this chapter and Chapter 413 if an
employee:
(1) elects not to participate in a regional network
established under Section 408.0221; or
(2) is employed by an employer for whom the insurance
carrier has not elected to participate in a regional network
established under Section 408.0221.
(s) An employee may change treating doctors within the
regional network established under Section 408.0221 in which the
employee is participating in accordance with the regional network
contract and is entitled to:
(1) make one change from the initial treating doctor
to an alternate treating doctor within the regional network unless
the change is for the purpose of securing a new impairment rating
or new determination of maximum medical improvement; and
(2) request additional changes of the treating doctor
in the manner provided by the regional network contract.
(t) An employee or insurance carrier may request that the
commission order an examination under Section 408.0041 if an
employee has received conflicting impairment ratings or
determinations of maximum medical improvement from more than one
treating doctor.
(u) For purposes of this section, the following is not a
selection of an alternate doctor in a regional network established
under Section 408.0221:
(1) a referral made by the doctor chosen by the
employee if the referral is medically reasonable and necessary;
(2) the receipt of services ancillary to surgery;
(3) the obtaining of a second opinion only on the
appropriateness of the diagnosis or treatment;
(4) the selection of a doctor because the original
doctor:
(A) dies;
(B) retires; or
(C) becomes unavailable or unable to provide
medical care to the employee; or
(5) a change of doctor required because of a change of
residence by the employee.
Sec. 408.0223. INSURANCE CARRIER NETWORKS. (a) In this
section, "insurance carrier network" means a voluntary workers'
compensation health care delivery network established by an
insurance carrier. The term does not include a regional network
established under Section 408.0221.
(b) This subtitle does not prohibit an insurance carrier,
whether doing business as an individual carrier or as a group, from
participating in or maintaining voluntary insurance carrier
networks if those voluntary insurance carrier networks allow
selection of doctors as provided by Section 408.022.
(c) This subtitle does not prohibit an insurance carrier
from concurrently participating in an insurance carrier network and
a regional network established under Section 408.0221.
SECTION 2.02. (a) The Texas Workers' Compensation Commission
shall adopt rules as required by Chapter 408, Labor Code, as
amended by this article, not later than October 1, 2002.
(b) The Texas Workers' Compensation Commission shall convene
the first meeting of the Health Care Network Advisory Committee
established under Section 408.0221, Labor Code, as added by this
article, not later than October 1, 2001.
(c) Unless determined to be unfeasible, the Texas Workers'
Compensation Commission shall contract for regional workers'
compensation health care delivery networks under Section 408.0221,
Labor Code, as added by this article, not later than December 31,
2002.
(d) Section 408.0222, Labor Code, as added by this article,
as that section affects workers' compensation benefits an employee
may receive for participating in a regional network under Section
408.0221, Labor Code, as added by this article, takes effect on the
certification by the Texas Workers' Compensation Commission that
the regional network is operational.
ARTICLE 3. RETURN-TO-WORK REPORTING AND SERVICES
SECTION 3.01. Section 409.005, Labor Code, is amended to
read as follows:
Sec. 409.005. REPORT OF INJURY; MODIFIED DUTY PROGRAM
NOTICE; ADMINISTRATIVE VIOLATION. (a) An employer shall report to
the employer's insurance carrier if:
(1) an injury results in the absence of an employee of
that employer from work for more than one day; or
(2) an employee of the employer notifies that employer
of an occupational disease under Section 409.001.
(b) The report under Subsection (a) must be made not later
than the eighth day after:
(1) the employee's absence from work for more than one
day due to an injury; or
(2) the day on which the employer receives notice
under Section 409.001 that the employee has contracted an
occupational disease.
(c) The employer shall deliver a written copy of the report
under Subsection (a) to the injured employee at the time that the
report is made to the insurance carrier.
(d) The insurance carrier shall file the report of the
injury on behalf of the policyholder. Except as provided by
Subsection (e), the insurance carrier must electronically file the
report with the commission not later than the seventh day after the
date on which the carrier receives the report from the employer.
(e) The executive director may waive the electronic filing
requirement under Subsection (d) and allow an insurance carrier to
mail or deliver the report to the commission not later than the
seventh day after the date on which the carrier receives the report
from the employer.
(f) A report required under this section may not be
considered to be an admission by or evidence against an employer or
an insurance carrier in a proceeding before the commission or a
court in which the facts set out in the report are contradicted by
the employer or insurance carrier.
(g) In addition to any information required under Subsection
(h), the report provided to the injured employee under Subsection
(c) must contain a summary written in plain language of the
employee's statutory rights and responsibilities under this
subtitle.
(h) The commission may adopt rules relating to:
(1) the information that must be contained in a report
required under this section, including the summary of rights and
responsibilities required under Subsection (g); and
(2) the development and implementation of an
electronic filing system for injury reports under this section.
(i) An employer and insurance carrier shall file subsequent
reports as required by commission rule.
(j) The employer shall, on the written request of the
employee, a doctor, the insurance carrier, or the commission,
notify the employee, the employee's treating doctor if known to the
employer, and the insurance carrier of the existence or absence of
opportunities for modified duty or a modified duty return-to-work
program available through the employer. If those opportunities or
that program exists, the employer shall identify the employer's
contact person and provide other information to assist the doctor,
the employee, and the insurance carrier to assess modified duty or
return-to-work options.
(k) This section does not prohibit the commission from
imposing requirements relating to return-to-work under other
authority granted to the commission in this subtitle.
(l) A person commits a violation if the person fails to
comply with this section unless good cause exists. A violation
under this subsection is a Class D administrative violation.
SECTION 3.02. Subchapter B, Chapter 413, Labor Code, is
amended by adding Section 413.021 to read as follows:
Sec. 413.021. RETURN-TO-WORK COORDINATION SERVICES. (a) An
insurance carrier shall, with the agreement of a participating
employer, provide the employer with return-to-work coordination
services as necessary to facilitate an employee's return to
employment. The insurance carrier shall notify the employer of the
availability of return-to-work coordination services. In offering
the services, insurance carriers and the commission shall target
employers without return-to-work programs and shall focus
return-to-work efforts on workers who begin to receive temporary
income benefits. These services may be offered by insurance
carriers in conjunction with the accident prevention services
provided under Section 411.061. Nothing in this section supersedes
the provisions of a collective bargaining agreement between an
employer and the employer's employees, and nothing in this section
authorizes or requires an employer to engage in conduct that would
otherwise be a violation of the employer's obligations under the
National Labor Relations Act (29 U.S.C. Section 151 et seq.), and
its subsequent amendments.
(b) Return-to-work coordination services under this section
may include:
(1) job analysis to identify the physical demands of a
job;
(2) job modification and restructuring assessments as
necessary to match job requirements with the functional capacity of
an employee; and
(3) medical or vocational case management to
coordinate the efforts of the employer, the treating doctor, and
the injured employee to achieve timely return to work.
(c) An insurance carrier is not required to provide physical
workplace modifications under this section and is not liable for
the cost of modifications made under this section to facilitate an
employee's return to employment.
(d) The commission shall use certified rehabilitation
counselors or other appropriately trained or credentialed
specialists to provide training to commission staff regarding the
coordination of return-to-work services under this section.
(e) The commission shall adopt rules necessary to collect
data on return-to-work outcomes to allow full evaluations of
successes and of barriers to achieving timely return to work after
an injury.
(f) The commission shall report twice annually to the
Research and Oversight Council on Workers' Compensation regarding
the implementation and outcome of the return-to-work initiatives
required by this section.
SECTION 3.03. The Texas Workers' Compensation Commission may
adopt rules as necessary to implement Sections 409.005(j) and
413.021, Labor Code, as added by this article, not earlier than
January 1, 2004.
ARTICLE 4. PREAUTHORIZATION, CONCURRENT REVIEW,
AND CERTIFICATION REQUIREMENTS
SECTION 4.01. Section 408.026, Labor Code, is amended to read
as follows:
Sec. 408.026. SPINAL SURGERY <SECOND OPINION>. <(a)> Except
in a medical emergency, an insurance carrier is liable for medical
costs related to spinal surgery only as provided by Section 413.014
and commission rules <if:>
<(1) before surgery, the employee obtains from a
doctor approved by the insurance carrier or the commission a second
opinion that concurs with the treating doctor's recommendation;>
<(2) the insurance carrier waives the right to an
examination or fails to request an examination before the 15th day
after the date of the notification that surgery is recommended; or>
<(3) the commission determines that extenuating
circumstances exist and orders payment for surgery>.
<(b) The commission shall adopt rules necessary to ensure
that an examination required under this section is performed
without undue delay.>
SECTION 4.02. Section 413.014, Labor Code, is amended to read
as follows:
Sec. 413.014. PREAUTHORIZATION REQUIREMENTS; CONCURRENT
REVIEW AND CERTIFICATION OF HEALTH CARE. (a) In this section,
"investigational or experimental service or device" means a health
care treatment, service, or device for which there is early,
developing scientific or clinical evidence demonstrating the
potential efficacy of the treatment, service, or device but that is
not yet broadly accepted as the prevailing standard of care.
(b) The commission by rule shall specify which health care
treatments and services require express preauthorization or
concurrent review by the insurance carrier. Treatments and services
for a medical emergency do not require express preauthorization.
(c) The commission rules adopted under this section must
provide that preauthorization and concurrent review are required at
a minimum for:
(1) spinal surgery, as provided by Section 408.026;
(2) work-hardening or work-conditioning services
provided by a health care facility that is not credentialed by an
organization recognized by commission rules;
(3) inpatient hospitalization, including any procedure
and length of stay;
(4) outpatient or ambulatory surgical services, as
defined by commission rule; and
(5) any investigational or experimental services or
devices.
(d) <(b)> The insurance carrier is not liable for those
specified treatments and services requiring preauthorization unless
preauthorization is sought by the claimant or health care provider
and either obtained from the insurance carrier or ordered by the
commission.
(e) The commission may not prohibit an insurance carrier and
a health care provider from voluntarily discussing health care
treatment and treatment plans, either prospectively or
concurrently, and may not prohibit an insurance carrier from
certifying or agreeing to pay for health care consistent with those
agreements.
SECTION 4.03. Subchapter B, Chapter 413, Labor Code, is
amended by adding Section 413.0141 to read as follows:
Sec. 413.0141. INITIAL PHARMACEUTICAL COVERAGE. The
commission may by rule provide that an insurance carrier shall
provide for payment of specified pharmaceutical services sufficient
for the first seven days following the date of injury if the health
care provider requests and receives verification of insurance
coverage and a verbal confirmation of an injury from the employer
or from the insurance carrier as provided by Section 413.014. The
rules adopted by the commission shall provide that an insurance
carrier is eligible for reimbursement for pharmaceutical services
paid under this section from the subsequent injury fund in the
event the injury is determined not to be compensable.
SECTION 4.04. The Texas Workers' Compensation Commission
shall adopt the rules required under Sections 408.026 and 413.014,
Labor Code, as amended by this article, not later than February 1,
2002. The changes in law made by Sections 408.026 and 413.014,
Labor Code, as amended by this article, apply only to health care
services requested or provided on or after the effective date of
the rules adopted by the commission, and the former law is
continued in effect for health care services requested or provided
before that date. The commission may adopt rules required by
Section 413.0141, Labor Code, as added by this article, on or after
September 1, 2002.
ARTICLE 5. REQUIRED MEDICAL EXAMINATIONS; DESIGNATED DOCTORS
SECTION 5.01. Sections 408.004(a) and (c), Labor Code, are
amended to read as follows:
(a) The commission may require an employee to submit to
medical examinations to resolve any question about:
(1) the appropriateness of the health care received by
the employee; or
(2) <the impairment caused by the compensable injury;>
<(3) the attainment of maximum medical improvement; or>
<(4)> similar issues.
(c) The insurance carrier shall pay for:
(1) an examination required under Subsection (a) or
(b); and
(2) the reasonable expenses <expense> incident to the
employee in submitting to the examination.
SECTION 5.02. Subchapter A, Chapter 408, Labor Code, is
amended by adding Section 408.0041 to read as follows:
Sec. 408.0041. DESIGNATED DOCTOR EXAMINATION. (a) At the
request of an insurance carrier or an employee, the commission
shall order a medical examination to resolve any question about:
(1) the impairment caused by the compensable injury;
or
(2) the attainment of maximum medical improvement.
(b) A medical examination requested under Subsection (a)
shall be performed by the next available doctor on the commission's
list of designated doctors whose credentials are appropriate for
the issue in question and the injured employee's medical condition.
The designated doctor doing the review must be trained and
experienced with the treatment and procedures used by the doctor
treating the patient's medical condition, and the treatment and
procedures performed must be within the scope of practice of the
designated doctor. The commission shall assign a designated doctor
not later than the 10th day after the date on which the request
under Subsection (a) is received, and the examination must be
conducted not later than the 21st day after the date on which the
commission issues the order under Subsection (a). An examination
under this section may not be conducted more frequently than every
60 days, unless good cause for more frequent examinations exists,
as defined by commission rules.
(c) The treating doctor and the insurance carrier are both
responsible for sending to the designated doctor all of the injured
employee's medical records relating to the issue to be evaluated by
the designated doctor that are in their possession. The treating
doctor and insurance carrier may send the records without a signed
release from the employee. The designated doctor is authorized to
receive the employee's confidential medical records to assist in
the resolution of disputes. The treating doctor and insurance
carrier may also send the designated doctor an analysis of the
injured employee's medical condition, functional abilities, and
return-to-work opportunities.
(d) To avoid undue influence on a person selected as a
designated doctor under this section, and except as provided by
Subsection (c), only the injured employee or an appropriate member
of the staff of the commission may communicate with the designated
doctor about the case regarding the injured employee's medical
condition or history before the examination of the injured employee
by the designated doctor. After that examination is completed,
communication with the designated doctor regarding the injured
employee's medical condition or history may be made only through
appropriate commission staff members. The designated doctor may
initiate communication with any doctor who has previously treated
or examined the injured employee for the work-related injury or
with peer reviewers identified by the insurance carrier.
(e) The designated doctor shall report to the commission.
The report of the designated doctor has presumptive weight unless
the great weight of the evidence is to the contrary. An employer
may make a bona fide offer of employment subject to Sections
408.103(e) and 408.144(c) based on the designated doctor's report.
(f) If an insurance carrier is not satisfied with the
opinion rendered by a designated doctor under this section, the
insurance carrier may request the commission to order an employee
to attend an examination by a doctor selected by the insurance
carrier. The commission shall allow the insurance carrier
reasonable time to obtain and present the opinion of the doctor
selected under this subsection before the commission makes a
decision on the merits of the issue in question.
(g) The insurance carrier shall pay for:
(1) an examination required under Subsection (a) or
(f); and
(2) the reasonable expenses incident to the employee
in submitting to the examination.
(h) An employee is not entitled to compensation, and an
insurance carrier is authorized to suspend the payment of temporary
income benefits, during and for a period in which the employee
fails to submit to an examination required by this chapter unless
the commission determines that the employee had good cause for the
failure to submit to the examination. The commission may order
temporary income benefits to be paid for the period for which the
commission determined that the employee had good cause. The
commission by rule shall ensure that:
(1) an employee receives reasonable notice of an
examination and the insurance carrier's basis for suspension; and
(2) the employee is provided a reasonable opportunity
to reschedule an examination for good cause.
(i) If the report of a designated doctor indicates that an
employee has reached maximum medical improvement, the insurance
carrier may suspend or reduce the payment of temporary income
benefits immediately.
(j) The employee or the insurance carrier may request that
the commission hold an expedited benefit review conference to
dispute a decision made under this section. The commission shall
adopt rules as necessary to implement this subsection. This
subsection expires September 1, 2003.
SECTION 5.03. Sections 408.122(b) and (c), Labor Code, are
amended to read as follows:
(b) To be eligible to serve as a designated doctor, a doctor
must meet specific qualifications, including training in the
determination of impairment ratings. The executive director shall
develop qualification standards and administrative policies to
implement this subsection, and the commission may adopt rules as
necessary. The designated doctor doing the review must be trained
and experienced with the treatment and procedures used by the
doctor treating the patient's medical condition, and the treatment
and procedures performed must be within the scope of practice of
the designated doctor. A designated doctor's credentials must be
appropriate for the issue in question and the injured employee's
medical condition. <To the extent possible, a designated doctor
must be in the same discipline and licensed by the same board of
examiners as the employee's doctor of choice.>
(c) <If a dispute exists as to whether the employee has
reached maximum medical improvement, the commission shall direct
the employee to be examined by a designated doctor chosen by mutual
agreement of the parties. If the parties are unable to agree on a
designated doctor, the commission shall direct the employee to be
examined by a designated doctor chosen by the commission. The
designated doctor shall report to the commission.> The report of
the designated doctor has presumptive weight, and the commission
shall base its determination of whether the employee has reached
maximum medical improvement on the report unless the great weight
of the other medical evidence is to the contrary.
SECTION 5.04. Section 408.125, Labor Code, is amended to read
as follows:
Sec. 408.125. DISPUTE AS TO IMPAIRMENT RATING. (a) If an
impairment rating is disputed, the commission shall direct the
employee to the next available doctor on the commission's list of
designated doctors, as provided by Section 408.0041 <be examined by
a designated doctor chosen by mutual agreement of the parties>.
(b) <If the parties are unable to agree on a designated
doctor, the commission shall direct the employee to be examined by
a designated doctor chosen by the commission.>
<(c)> The designated doctor shall report in writing to the
commission.
(c) The <(d) If the designated doctor is chosen by the
parties, the commission shall adopt the impairment rating made by
the designated doctor.>
<(e) If the designated doctor is chosen by the commission,
the> report of the designated doctor shall have presumptive weight,
and the commission shall base the impairment rating on that report
unless the great weight of the other medical evidence is to the
contrary. If the great weight of the medical evidence contradicts
the impairment rating contained in the report of the designated
doctor chosen by the commission, the commission shall adopt the
impairment rating of one of the other doctors.
(d) <(f)> To avoid undue influence on a person selected as a
designated doctor under this section, only the injured employee or
an appropriate member of the staff of the commission may
communicate with the designated doctor about the case regarding the
injured employee's medical condition or history before the
examination of the injured employee by the designated doctor. After
that examination is completed, communication with the designated
doctor regarding the injured employee's medical condition or
history may be made only through appropriate commission staff
members. The designated doctor may initiate communication with any
doctor who has previously treated or examined the injured employee
for the work-related injury.
(e) Notwithstanding Subsection (d), the treating doctor and
the insurance carrier are both responsible for sending to the
designated doctor all the injured employee's medical records that
are in their possession and that relate to the issue to be
evaluated by the designated doctor. The treating doctor and the
insurance carrier may send the records without a signed release
from the employee. The designated doctor is authorized to receive
the employee's confidential medical records to assist in the
resolution of disputes. The treating doctor and the insurance
carrier may also send the designated doctor an analysis of the
injured employee's medical condition, functional abilities, and
return-to-work opportunities.
(f) <(g)> A violation of Subsection (d) <(f)> is a Class C
administrative violation.
SECTION 5.05. The Research and Oversight Council on Workers'
Compensation shall report to the legislature not later than
December 31, 2004, regarding issues related to medical examinations
conducted under Section 408.0041, Labor Code, as added by this
article.
SECTION 5.06. Section 408.004, Labor Code, as amended by this
article, and Section 408.0041, Labor Code, as added by this
article, apply only to a request for a medical examination made to
the Texas Workers' Compensation Commission by an insurance carrier
on or after January 1, 2002.
ARTICLE 6. MEDICAL BENEFIT REGULATION; DISPUTE RESOLUTION
SECTION 6.01. Section 408.028, Labor Code, is amended to read
as follows:
Sec. 408.028. PHARMACEUTICAL SERVICES. (a) A physician
<health care practitioner> providing care to an employee under this
subchapter shall prescribe for the employee any necessary
prescription drugs, and order over-the-counter alternatives to
prescription medications as clinically appropriate and applicable,
in accordance with applicable state law and as provided by
Subsection (b). A doctor providing care may order over-the-counter
alternatives to prescription medications, when clinically
appropriate, in accordance with applicable state law and as
provided by Subsection (b).
(b) The commission by rule shall develop an open formulary
under Section 413.011 that requires the use of generic
pharmaceutical medications and clinically appropriate
over-the-counter alternatives to prescription medications unless
otherwise specified by the prescribing doctor, in accordance with
applicable state law.
(c) Except as otherwise provided by this subtitle, an <An>
insurance carrier may not require an employee to use pharmaceutical
services designated by the carrier.
(d) The commission shall adopt rules to allow an employee to
purchase over-the-counter alternatives to prescription medications
prescribed or ordered under Subsection (a) or (b) and to obtain
reimbursement from the insurance carrier for those medications.
SECTION 6.02. Section 413.011, Labor Code, is amended to read
as follows:
Sec. 413.011. REIMBURSEMENT POLICIES AND GUIDELINES;
TREATMENT GUIDELINES <AND MEDICAL POLICIES>. (a) The commission
<by rule> shall use health care reimbursement policies and
guidelines that reflect the standardized reimbursement structures
found in other health care delivery systems with minimal
modifications to those reimbursement methodologies as necessary to
meet occupational injury requirements. To achieve standardization,
the commission shall adopt the most current reimbursement
methodologies, models, and values or weights used by the federal
Health Care Financing Administration, including applicable payment
policies relating to coding, billing, and reporting, and may modify
documentation requirements as necessary to meet the requirements of
Section 413.053.
(b) In determining the appropriate fees, the commission
shall also develop conversion factors or other payment adjustment
factors taking into account economic indicators in health care and
the requirements of Subsection (d). The commission shall also
provide for reasonable fees for the evaluation and management of
care as required by Section 408.025(c) and commission rules. This
section does not adopt the Medicare fee schedule, and the
commission shall not adopt conversion factors or other payment
adjustment factors based solely on those factors as developed by
the federal Health Care Financing Administration.
(c) This section may not be interpreted in a manner that
would discriminate in the amount or method of payment or
reimbursement for services in a manner prohibited by Section 3(d),
Article 21.52, Insurance Code, or as restricting the ability of
chiropractors to serve as treating doctors as authorized by this
subtitle. The commission shall also develop guidelines relating to
<establish medical policies and guidelines relating to:>
<(1) fees charged or paid for medical services for
employees who suffer compensable injuries, including guidelines
relating to payment of fees for specific medical treatments or
services;>
<(2) use of medical services by employees who suffer
compensable injuries; and>
<(3)> fees charged or paid for providing expert
testimony relating to an issue arising under this subtitle.
(d) <(b)> Guidelines for medical services fees must be fair
and reasonable and designed to ensure the quality of medical care
and to achieve effective medical cost control. The guidelines may
not provide for payment of a fee in excess of the fee charged for
similar treatment of an injured individual of an equivalent
standard of living and paid by that individual or by someone acting
on that individual's behalf. The commission shall consider the
increased security of payment afforded by this subtitle in
establishing the fee guidelines.
(e) The commission by rule may adopt treatment guidelines,
including return-to-work guidelines. If adopted, treatment
guidelines adopted must be nationally recognized, scientifically
valid, and outcome-based and designed to reduce excessive or
inappropriate medical care while safeguarding necessary medical
care <(c) Medical policies adopted by the commission must be
consistent with Sections 413.013, 413.020, 413.052, and 413.053>.
(f) <(d)> The commission by rule may <shall> establish
medical policies or treatment guidelines relating to necessary
treatments for injuries.
(g) Any medical <Medical> policies or guidelines adopted by
the commission must <shall> be:
(1) designed to ensure the quality of medical care and
to achieve effective medical cost control;
(2) designed to enhance a timely and appropriate
return to work; and
(3) consistent with Sections 413.013, 413.020,
413.052, and 413.053.
SECTION 6.03. Section 413.015(a), Labor Code, is amended to
read as follows:
(a) Insurance carriers shall make appropriate payment of
charges for medical services provided under this subtitle. An
insurance carrier may contract with a separate entity to forward
payments for medical services. Any payment due the insurance
carrier from the separate entity must be made in accordance with
the contract. The separate entity is subject to the direction of
the insurance carrier, and the insurance carrier is responsible for
the actions of the separate entity under this subsection.
SECTION 6.04. Section 413.031, Labor Code, is amended to read
as follows:
Sec. 413.031. MEDICAL DISPUTE RESOLUTION. (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) denied authorization for the payment for the
service requested or performed if authorization is required or
allowed by this subtitle or <the medical policies of the>
commission rules; <or>
(3) ordered by the commission <division> to refund a
payment received; or
(4) ordered to make a payment that was refused or
reduced for a medical service rendered.
(b) A health care provider who submits a charge in excess of
the fee guidelines or treatment policies is entitled to a review of
the medical service to determine if reasonable medical
justification exists for the deviation. A claimant is entitled to
a review of a medical service for which preauthorization is sought
by the health care provider and denied by the insurance carrier.
The commission shall adopt rules to notify claimants of their
rights under this subsection.
(c) In resolving disputes over the amount of payment due for
services determined to be medically necessary and appropriate for
treatment of a compensable injury, the role of the commission is to
adjudicate the payment given the relevant statutory provisions and
commission rules. The commission shall publish on its Internet
website its medical dispute decisions, including decisions of
independent review organizations, and any subsequent decisions by
the State Office of Administrative Hearings. Before publication,
the commission shall redact only that information necessary to
prevent identification of the injured worker.
(d) A review of the medical necessity of a health care
<medical> service requiring preauthorization under Section 413.014
or commission rules under that <this> section shall be conducted by
an independent review organization under Article 21.58C, 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 <provided by a health care
provider professional review organization if requested by the
health care practitioner or if ordered by the commission>.
(e) Except as provided by Subsection (d), a review of the
medical necessity of a health care service provided under this
chapter or Chapter 408 shall be conducted by an independent review
organization under Article 21.58C, 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.
(f) The commission by rule shall specify the appropriate
dispute resolution process for disputes in which a claimant has
paid for medical services and seeks reimbursement.
(g) In performing a review of medical necessity under
Subsection (d) or (e), an independent review organization may
request that the commission order an examination by a designated
doctor under Chapter 408.
(h) The insurance carrier shall pay the cost of the review
if the dispute arises in connection with a request for health care
services that require preauthorization under Section 413.014 or
commission rules under that section.
(i) Except as provided by Subsection (h), the cost of the
review shall be paid by the nonprevailing party.
(j) Notwithstanding Subsections (h) and (i), an employee may
not be required to pay any portion of the cost of a review.
(k) Except as provided by Subsection (l), a <(d) A> party
to a medical dispute that remains unresolved after a review of the
medical service under this section is entitled to a hearing. The
hearing shall be conducted by the State Office of Administrative
Hearings within 90 days of receipt of a request for a hearing in
the manner provided for a contested case under Chapter 2001,
Government Code (the administrative procedure law). A party who has
exhausted the party's administrative remedies under this subtitle
and who is aggrieved by a final decision of the State Office of
Administrative Hearings may seek judicial review of the decision.
Judicial review under this subsection shall be conducted in the
manner provided for judicial review of contested cases under
Subchapter G, Chapter 2001, Government Code.
(l) A party to a medical dispute regarding spinal surgery
that remains unresolved after a review by an independent review
organization as provided by Subsections (d) and (e) is entitled to
dispute resolution as provided by Chapter 410.
SECTION 6.05. Section 413.041, Labor Code, is amended to read
as follows:
Sec. 413.041. DISCLOSURE. (a) Each health care practitioner
shall disclose to the commission the identity of any health care
provider in which the health care practitioner, or the health care
provider that employs the health care practitioner, has a financial
interest. The health care practitioner shall make the disclosure
in the manner provided by commission rule.
(b) The commission shall require by rule that a doctor
disclose financial interests in other health care providers as a
condition of registration for the approved doctor list established
under Section 408.023 and shall define "financial interest" for
purposes of this subsection as provided by analogous federal
regulations. The commission by rule shall adopt the federal
standards that prohibit the payment or acceptance of payment in
exchange for health care referrals relating to fraud, abuse, and
anti-kickbacks.
(c) A health care provider that fails to comply with this
section is subject to penalties and sanctions as provided by this
subtitle, including forfeiture of the right to reimbursement for
services rendered during the period of noncompliance.
(d) The commission shall publish all final disclosure
enforcement orders issued under this section on the commission's
Internet website. <A health care provider who refers a workers'
compensation claimant to another health care provider in which the
referring provider has more than a five percent financial interest
shall file an annual disclosure statement with the commission as
provided by commission rules and shall disclose the interest to the
insurance carrier at the time of the referral. The referring
provider shall specify the degree of the financial interest and
shall provide other information as required by commission rules.>
SECTION 6.06. Section 415.0035, Labor Code, is amended by
adding Subsections (e) and (f) to read as follows:
(e) An insurance carrier or health care provider commits an
administrative violation if that person violates this subtitle or a
rule, order, or decision of the commission.
(f) A subsequent administrative violation under this
section, after prior notice to the insurance carrier or health care
provider of noncompliance, is subject to penalties as provided by
Section 415.021. Prior notice under this subsection is not required
if the violation was committed wilfully or intentionally, or if the
violation was of a decision or order of the commission.
SECTION 6.07. Section 415.021(a), Labor Code, is amended to
read as follows:
(a) The commission may assess an administrative penalty
against a person who commits an administrative violation.
Notwithstanding Subsection (c), the commission by rule shall adopt
a schedule of specific monetary administrative penalties for
specific violations under this subtitle.
SECTION 6.08. Section 415.023, Labor Code, is amended to read
as follows:
Sec. 415.023. COMMISSION OF WRONGFUL ACT AS MATTER OF
PRACTICE; ADMINISTRATIVE VIOLATION. (a) A person who commits an
administrative violation under Section 415.001, 415.002, <or>
415.003, or 415.0035 as a matter of practice is subject to an
applicable rule adopted under Subsection (b) in addition to the
penalty assessed for the violation.
(b) The commission may adopt rules providing for:
(1) a reduction or denial of fees;
(2) public or private reprimand by the commission;
(3) suspension from practice before the commission;
<or>
(4) restriction, suspension, or revocation of the
right to receive reimbursement under this subtitle; or
(5) referral and petition to the appropriate licensing
authority for appropriate disciplinary action, including the
restriction, suspension, or revocation of the person's license.
SECTION 6.09. (a) The Texas Workers' Compensation Commission
shall adopt the rules required by Section 408.028, Labor Code, as
amended by this article, not later than February 1, 2002.
(b) The Texas Workers' Compensation Commission shall adopt
the rules and fee guidelines under Section 413.011, Labor Code, as
amended by this article, not later than May 1, 2002. The treatment
guidelines adopted under Chapter 413, Labor Code, in effect
immediately before September 1, 2001, are abolished on January 1,
2002.
(c) The Texas Workers' Compensation Commission shall adopt
rules as required by Section 413.041, Labor Code, as amended by
this article, not later than June 1, 2002.
(d) The change in law made by this article by the amendment
of Section 413.031, Labor Code, applies only to a request for a
review of medical services filed with the Texas Workers'
Compensation Commission on or after January 1, 2002. A request
filed with the commission before that date is covered by the law in
effect immediately before January 1, 2002, and that law is
continued in effect for that purpose.
(e) Section 413.041(c), Labor Code, as added by this
article, applies only to a failure to comply with Section 413.041
that occurs after June 1, 2002.
(f) Sections 415.023 and 415.0035, Labor Code, as amended by
this article, apply only to a violation occurring on or after
September 1, 2001.
ARTICLE 7. SUNSET REVIEW; AUDIT
SECTION 7.01. Section 401.002, Labor Code, is amended to read
as follows:
Sec. 401.002. APPLICATION OF SUNSET ACT. The Texas Workers'
Compensation Commission is subject to Chapter 325, Government Code
(Texas Sunset Act). Unless continued in existence as provided by
that chapter, the commission is abolished September 1, 2005 <2007>.
SECTION 7.02. Subchapter A, Chapter 401, Labor Code, is
amended by adding Section 401.003 to read as follows:
Sec. 401.003. ACTIVITIES OF THE STATE AUDITOR. (a) The
commission is subject to audit by the state auditor in accordance
with Chapter 321, Government Code. The state auditor may audit the
commission's:
(1) structure and internal controls;
(2) level and quality of service provided to
employers, injured employees, insurance carriers, self-insured
governmental entities, and other participants;
(3) implementation of statutory mandates;
(4) employee turnover;
(5) information management systems, including public
access to nonconfidential information;
(6) adoption and implementation of administrative
rules; and
(7) assessment of administrative violations and the
penalties for those violations.
(b) Nothing in this section limits the authority of the
state auditor under Chapter 321, Government Code.
ARTICLE 8. ATTORNEY'S FEES
SECTION 8.01. Section 408.221, Labor Code, is amended to read
as follows:
Sec. 408.221. ATTORNEY'S FEES PAID TO CLAIMANT'S COUNSEL.
(a) An attorney's fee, including a contingency fee, for
representing a claimant before the commission or court under this
subtitle must be approved by the commission or court.
(b) Except as otherwise provided, an attorney's fee under
this section is based on the attorney's time and expenses according
to written evidence presented to the commission or court. Except as
provided by Subsection (c) or Section 408.147(c), the attorney's
fee shall be paid from the claimant's recovery.
(c) An insurance carrier that seeks judicial review under
Subchapter G, Chapter 410, of a final decision of a commission
appeals panel regarding compensability or eligibility for, or the
amount of, income or death benefits is liable for reasonable and
necessary attorney's fees as provided by Subsection (d) incurred by
the claimant as a result of the insurance carrier's appeal if the
claimant prevails on an issue on which judicial review is sought by
the insurance carrier in accordance with the limitation of issues
contained in Section 410.302. If the carrier appeals multiple
issues and the claimant prevails on some, but not all, of the
issues appealed, the court shall apportion and award fees to the
claimant's attorney only for the issues on which the claimant
prevails. In making that apportionment, the court shall consider
the factors prescribed by Subsection (d). This subsection does not
apply to attorney's fees for which an insurance carrier may be
liable under Section 408.147. An award of attorney's fees under
this subsection is not subject to commission rules adopted under
Subsection (f). This subsection expires September 1, 2005.
(d) In approving an attorney's fee under this section, the
commission or court shall consider:
(1) the time and labor required;
(2) the novelty and difficulty of the questions
involved;
(3) the skill required to perform the legal services
properly;
(4) the fee customarily charged in the locality for
similar legal services;
(5) the amount involved in the controversy;
(6) the benefits to the claimant that the attorney is
responsible for securing; and
(7) the experience and ability of the attorney
performing the services.
(e) <(d)> The commission by rule or the court may provide
for the commutation of an attorney's fee, except that the
attorney's fee shall be paid in periodic payments in a claim
involving death benefits if the only dispute is as to the proper
beneficiary or beneficiaries.
(f) <(e)> The commission by rule shall provide guidelines
for maximum attorney's fees for specific services in accordance
with this section.
(g) <(f)> An attorney's fee may not be allowed in a case
involving a fatal injury or lifetime income benefit if the
insurance carrier admits liability on all issues and tenders
payment of maximum benefits in writing under this subtitle while
the claim is pending before the commission.
(h) <(g)> An attorney's fee shall be paid to the attorney by
separate draft.
(i) <(h)> Except as provided by Subsection (c) or Section
408.147(c), an attorney's fee may not exceed 25 percent of the
claimant's recovery.
SECTION 8.02. Section 408.147(c), Labor Code, is amended to
read as follows:
(c) If an insurance carrier disputes a commission
determination that an employee is entitled to supplemental income
benefits or the amount of supplemental income benefits due and the
employee prevails on any disputed issue, the insurance carrier is
liable for reasonable and necessary attorney's fees incurred by the
employee as a result of the insurance carrier's dispute and for
supplemental income benefits accrued but not paid and interest on
that amount, according to Section 408.064. Attorney's fees awarded
under this subsection are not subject to Sections 408.221(b), (f)
<(e)>, and (i) <(h)>.
SECTION 8.03. Section 408.222(b), Labor Code, is amended to
read as follows:
(b) In determining whether a fee is reasonable under this
section, the commission or court shall consider issues analogous to
those listed under Section 408.221(d) <408.221(c)>. The defense
counsel shall present written evidence to the commission or court
relating to:
(1) the time spent and expenses incurred in defending
the case; and
(2) other evidence considered necessary by the
commission or court in making a determination under this section.
SECTION 8.04. The change in law made by this article applies
only to a request for judicial review that occurs on or after
September 1, 2001. A request for judicial review that occurs
before that date is governed by the law in effect on the date the
request is made, and the former law is continued in effect for that
purpose.
ARTICLE 9. LIFETIME INCOME BENEFITS
SECTION 9.01. Section 408.161(a), Labor Code, is amended to
read as follows:
(a) Lifetime income benefits are paid until the death of the
employee for:
(1) total and permanent loss of sight in both eyes;
(2) loss of both feet at or above the ankle;
(3) loss of both hands at or above the wrist;
(4) loss of one foot at or above the ankle and the
loss of one hand at or above the wrist;
(5) an injury to the spine that results in permanent
and complete paralysis of both arms, both legs, or one arm and one
leg; <or>
(6) a physically traumatic injury to the brain
resulting in incurable insanity or imbecility; or
(7) third degree burns that cover at least 40 percent
of the body and require grafting, or third degree burns covering
the majority of either both hands or one hand and the face.
ARTICLE 10. AVERAGE WEEKLY WAGE; MULTIPLE EMPLOYMENT; SUBSEQUENT
INJURY FUND
SECTION 10.01. Section 403.006, Labor Code, is amended by
amending Subsection (b) and adding Subsection (d) to read as
follows:
(b) The subsequent injury fund is liable for:
(1) the payment of compensation as provided by Section
408.162;
(2) reimbursement of insurance carrier claims of
overpayment of benefits made under an interlocutory order or
decision of the commission as provided by this subtitle, consistent
with the priorities established by rule by the commission;
(3) reimbursement of insurance carrier claims as
provided by Sections 408.042 and 413.0141, consistent with the
priorities established by rule by the commission; and
(4) the payment of an assessment of feasibility and
the development of regional networks established under Section
408.0221.
(d) Based on an actuarial assessment of the funding
available under Section 403.007(e), the commission may make partial
payment of insurance carrier claims under Subsection (b)(3).
SECTION 10.02. Section 403.007, Labor Code, is amended by
adding Subsections (e) and (f) to read as follows:
(e) If the commission determines that the funding under
Subsection (a) is not adequate to meet the expected obligations of
the subsequent injury fund established under Section 403.006, the
fund shall be supplemented by the collection of a maintenance tax
paid by insurance carriers, other than a governmental entity, as
provided by Sections 403.002 and 403.003. The rate of assessment
must be adequate to provide 120 percent of the projected unfunded
liabilities of the fund for the next biennium as certified by an
independent actuary or financial advisor.
(f) The commission's actuary or financial advisor shall
report biannually to the Research and Oversight Council on Workers'
Compensation on the financial condition and projected assets and
liabilities of the subsequent injury fund. The commission shall
make the reports available to members of the legislature and the
public. The commission may purchase annuities to provide for
payments due to claimants under this subtitle if the commission
determines that the purchase of annuities is financially prudent
for the administration of the fund.
SECTION 10.03. Section 408.042, Labor Code, is amended to
read as follows:
Sec. 408.042. AVERAGE WEEKLY WAGE FOR PART-TIME EMPLOYEE OR
EMPLOYEE WITH MULTIPLE EMPLOYMENT. (a) The average weekly wage of
a part-time employee who limits the employee's work to less than
<full-time hours or> a full-time workweek as a regular course of
that employee's conduct is computed as provided by Section 408.041.
(b) For part-time employees not covered by Subsection (a),
the average weekly wage:
(1) for determining temporary income benefits is
computed as provided by Section 408.041; and
(2) for determining impairment income benefits,
supplemental income benefits, lifetime income benefits, and death
benefits is computed as follows:
(A) if the employee has worked for the employer
for at least the 13 weeks immediately preceding the date of the
injury, the average weekly wage is computed by dividing the sum of
the wages paid in the 13 consecutive weeks immediately preceding
the date of the injury by 13 and adjusting that amount to the
weekly wage level the employee would have attained by working a
full-time workweek at the same rate of pay; or
(B) if the employee has worked for the employer
for less than 13 weeks immediately preceding the date of the
injury, the average weekly wage is equal to:
(i) the weekly wage that the employer pays
a similar employee for similar services based on a <in> full-time
workweek <employment>; or
(ii) if a similar employee does not exist,
the usual wage paid in that vicinity for the same or similar
services based on a <provided for compensation in> full-time
workweek <employment>.
(c) For employees with multiple employment, the average
weekly wage for determining temporary income benefits, impairment
income benefits, supplemental income benefits, lifetime income
benefits, and death benefits, is computed as follows:
(1) the average weekly wage for an employee with
multiple employment is equal to the sum of the average weekly wages
computed under Subdivisions (2) and (3);
(2) for each of the employers for whom the employee
has worked for at least the 13 weeks immediately preceding the date
of injury, the average weekly wage is equal to the sum of the wages
paid by that employer to the employee in the 13 weeks immediately
preceding the injury divided by 13;
(3) for each of the employers for whom the employee
has worked for less than the 13 weeks immediately preceding the
date of the injury, the average weekly wage is equal to:
(A) the weekly wage that employer pays similar
employees for similar services; or
(B) if a similar employee does not exist, the
usual weekly wage paid in that vicinity for the same or similar
services; and
(4) the average weekly wage of an employee with
multiple employment who limits the employee's work to less than a
full-time workweek, but does not do so as a regular course of that
employee's conduct, is adjusted to the weekly wage level the
employee would have attained by working a full-time workweek at the
employee's average rate of pay.
(d) The commission shall:
(1) prescribe a form to collect information regarding
the wages of employees with multiple employment; and
(2) by rule, determine the manner by which the
commission collects and distributes wage information to implement
this section.
(e) For an employee with multiple employment, only the
employee's wages that are reportable for federal income tax
purposes may be considered. The employee shall document and verify
wage payments subject to this section.
(f) If the commission determines that computing the average
weekly wage for an employee as provided by Subsection (c) is
impractical or unreasonable, the commission shall set the average
weekly wage in a manner that more fairly reflects the employee's
average weekly wage and that is fair and just to both parties or is
in the manner agreed to by the parties. The commission by rule may
define methods to determine a fair and just average weekly wage
consistent with this section.
(g) An insurance carrier is entitled to apply for and
receive reimbursement at least annually from the subsequent injury
fund for the amount of income benefits paid to a worker under this
section that are based on employment other than the employment
during which the compensable injury occurred. The commission may
adopt rules that govern the documentation, application process, and
other administrative requirements necessary to implement this
subsection.
(h) In this section:
(1) "Employee with multiple employment" means an
employee who has more than one employer.
(2) "Full-time workweek" means a 40-hour workweek.
(3) "Part-time<, "part-time> employee" means an
employee who, at the time of the injury, was working less than a
<the> full-time <hours or full-time> workweek for the employer for
whom the employee was working when the compensable injury occurred
<of similar employees in the same employment, whether for the same
or a different employer>.
SECTION 10.04. Subchapter C, Chapter 408, Labor Code, is
amended by adding Section 408.0446 to read as follows:
Sec. 408.0446. AVERAGE WEEKLY WAGE; SCHOOL DISTRICT
EMPLOYEE. (a) For determining the amount of temporary income
benefits of a school district employee under Chapter 504, the
average weekly wage is computed on the basis of wages earned in a
week rather than on the basis of wages paid in a week. The wages
earned in any given week are equal to the amount that would be
deducted from an employee's salary if the employee were absent from
work for one week and the employee did not have personal leave
available to compensate the employee for lost wages for that week.
(b) An insurance carrier may adjust a school district
employee's average weekly wage as often as necessary to reflect the
wages the employee reasonably could expect to earn during the
period for which temporary income benefits are paid. In adjusting
a school district employee's average weekly wage under this
subsection, the insurance carrier may consider any evidence of the
employee's reasonable expectation of earnings.
(c) For determining the amount of impairment income
benefits, supplemental income benefits, lifetime income benefits,
or death benefits of a school district employee under Chapter 504,
the average weekly wage of the employee is computed by dividing the
total amount of wages earned by the employee during the 12 months
immediately preceding the date of the injury by 50.
(d) If the commission determines that computing the average
weekly wage of a school district employee as provided by this
section is impractical because the employee did not earn wages
during the 12 months immediately preceding the date of the injury,
the commission shall compute the average weekly wage in a manner
that is fair and just to both parties.
(e) The commission shall adopt rules as necessary to
implement this section.
SECTION 10.05. (a) Except as provided by Subsection (b) of
this section, the change in law made by this article applies only
to a claim for workers' compensation benefits based on a
compensable injury that occurs on or after July 1, 2002. A claim
based on a compensable injury that occurs before that date 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.
(b) Section 408.0446, Labor Code, as added by this article,
takes effect December 1, 2001, and applies only to a claim for
workers' compensation benefits based on a compensable injury that
occurs on or after that date. A claim based on a compensable
injury that occurs before that date is governed by the law in
effect on the date that the compensable injury occurred, and the
former law is continued in effect for that purpose.
ARTICLE 11. INSURANCE CARRIER INFORMATION
SECTION 11.01. Section 410.164, Labor Code, is amended by
adding Subsection (c) to read as follows:
(c) At each contested case hearing, as applicable, the
insurance carrier shall file with the hearing officer and shall
deliver to the claimant a single document stating the true
corporate name of the insurance carrier and the name and address of
the insurance carrier's registered agent for service of process.
The document is part of the record of the contested case hearing.
SECTION 11.02. Section 410.204, Labor Code, is amended by
adding Subsection (d) to read as follows:
(d) Each final decision of the appeals panel shall conclude
with a separate paragraph stating: "The true corporate name of the
insurance carrier is (NAME IN BOLD PRINT) and the name and address
of its registered agent for service of process is (NAME AND ADDRESS
IN BOLD PRINT)."
SECTION 11.03. The change in law made by this article applies
only to a workers' compensation hearing that is conducted on or
after the effective date of this Act. A hearing that is conducted
before that date is governed by the law in effect on the date the
hearing was conducted, and the former law is continued in effect
for that purpose.
ARTICLE 12. APPEAL REQUIREMENTS
SECTION 12.01. Section 410.202, Labor Code, is amended by
adding Subsection (d) to read as follows:
(d) Saturdays and Sundays and holidays listed in Section
662.003, Government Code, are not included in the computation of
the time in which a request for an appeal under Subsection (a) or
a response under Subsection (b) must be filed.
SECTION 12.02. The change in law made by this article applies
only to an appeal in a workers' compensation proceeding filed on or
after the effective date of this Act. An appeal filed before the
effective date of this Act is governed by the law in effect on the
date the appeal was filed, and the former law is continued in
effect for that purpose.
ARTICLE 13. STUDY ON DRUG-FREE WORKPLACE REQUIREMENTS
SECTION 13.01. Subchapter G, Chapter 411, Labor Code, is
amended by adding Section 411.093 to read as follows:
Sec. 411.093. STUDY ON DRUG-FREE WORKPLACE; REPORT. (a) The
commission shall study:
(1) the implementation and development of drug-free
workplace policies under this subchapter;
(2) the use of drug-free workplace requirements
adopted by other jurisdictions to reduce the adverse impact on the
operation of workers' compensation insurance systems of drug abuse
and its effects in the workplace; and
(3) any other aspects of the effect of drug abuse on
the operation of the workers' compensation insurance system in this
state as considered appropriate by the commission or the Research
and Oversight Council on Workers' Compensation.
(b) The commission shall report not later than February 1,
2003, to the legislature and the Research and Oversight Council on
Workers' Compensation regarding the study conducted under this
section. The report must include:
(1) any commission recommendations for legislative
changes in the workers' compensation laws regarding the
implementation of a drug-free workplace requirement; and
(2) an analysis of the possible effects of the
adoption of a workers' compensation insurance premium discount
program for employers who maintain a drug-free workplace on the
operation of the workers' compensation insurance system in this
state.
(c) On the request of the commission, the Texas Department
of Insurance shall assist the commission in the performance of its
duties under this section.
(d) This section expires September 1, 2003.
ARTICLE 14. WORKERS' COMPENSATION
FOR STATE EMPLOYEES
SECTION 14.01. Section 412.012, Labor Code, is amended to
read as follows:
Sec. 412.012. FUNDING. <(a)> The office shall be
administered through money appropriated by the legislature and
through <(1) interagency contracts for the risk management program
and (2)> the allocation program for the financing of state
workers' compensation benefits and risk management costs.
Sec. 412.0121. INTERAGENCY CONTRACTS. (a) <(b) Interagency
Contracts. (1)> Each state agency shall enter into an interagency
contract with the office under Chapter 771, Government Code, to pay
the costs incurred by the office in administering this chapter for
the benefit of that state agency.
(b) Costs payable under the contract include the cost of:
(1) <(A)> services of office employees;
(2) <(B)> materials; and
(3) <(C)> equipment, including computer hardware and
software.
(c) <(2)> The <amount of the> costs of risk management
services provided <to be paid> by a state agency under the
interagency contract shall be allocated in the same proportion and
determined in the same manner as the costs of workers' compensation
<is based on:>
<(A) the number of employees of the agency
compared with the total number of employees of all state agencies
to which this chapter applies;>
<(B) the dollar value of the agency's property
and asset and liability exposure compared to that of all state
agencies to which this chapter applies; and>
<(C) the number and aggregate cost of claims and
losses incurred by the state agency compared to those incurred by
all state agencies to which this chapter applies>.
Sec. 412.0122. STATE SELF-INSURING FOR WORKERS'
COMPENSATION. <(c)> The state is self-insuring with respect to an
employee's compensable injury. <The legislature shall appropriate
the amount designated by the appropriation structure for the
payment of state workers' compensation claims costs to the office.
This section does not affect the reimbursement of claims costs by
funds other than general revenue funds, as provided by the General
Appropriations Act.>
Sec. 412.0123. ALLOCATION OF WORKERS' COMPENSATION AND RISK
MANAGEMENT COSTS; RISK REWARD PROGRAM. (a) The office shall
establish a risk reward for the payment of workers' compensation
claims and risk management services that are incurred by a state
agency subject to Chapter 501.
(b) The office shall establish a formula for allocating the
state's workers' compensation costs among covered agencies based on
the claims experience of each agency, the current and projected
size of each agency's workforce, each agency's payroll, the related
costs incurred in administering claims, and other factors that the
office determines to be relevant. The agency may provide modifiers
to the formula to promote the effective implementation of risk
management programs by state agencies.
(c) The board has final authority to determine the
assessments to be paid by the covered agencies.
Sec. 412.0124. DEPOSIT OF WORKERS' COMPENSATION SUBROGATION
RECOVERIES. <(d) State Workers' Compensation Account. (1)> All
money recovered by the director from a third party through
subrogation shall be deposited into the state workers' compensation
account in general revenue.
<(2) Funds deposited under this section may be used
for the payment of compensation and other benefits to state
employees.>
SECTION 14.02. Section 501.001(5), Labor Code, is amended to
read as follows:
(5) "Employee" means a person who is:
(A) in the service of the state pursuant to an
election, appointment, or express oral or written contract of hire;
(B) paid from state funds but whose duties
require that the person work and frequently receive supervision in
a political subdivision of the state;
(C) a peace officer employed by a political
subdivision, while the peace officer is exercising authority
granted under:
(i) Article 12, Code of Criminal Procedure;
or
(ii) Articles 14.03(d) and (g) <Article
14.03(c)>, Code of Criminal Procedure; or
(D) a member of the state military forces, as
defined by Section 431.001, Government Code, who is engaged in
authorized training or duty.
SECTION 14.03. Subchapter C, Chapter 505, Labor Code, is
amended by adding Section 505.060 to read as follows:
Sec. 505.060. EFFECT OF SICK LEAVE; ANNUAL LEAVE. (a) An
employee may elect to use accrued sick leave before receiving
income benefits. If an employee elects to use sick leave, the
employee is not entitled to income benefits under this chapter
until the employee has exhausted the employee's accrued sick leave.
(b) An employee may elect to use all or any number of weeks
of accrued annual leave after the employee's accrued sick leave is
exhausted. If an employee elects to use annual leave, the employee
is not entitled to income benefits under this chapter until the
elected number of weeks of leave have been exhausted.
ARTICLE 15. INTEREST OR DISCOUNT RATE
SECTION 15.01. Section 401.023(b), Labor Code, is amended to
read as follows:
(b) The commission shall compute and publish the interest
and discount rate quarterly, using the treasury constant maturity
<auction> rate <quoted on a discount basis> for one-year <the
52-week> treasury bills issued by the United States government, as
published by the Federal Reserve Board on <the date nearest to> the
15th day preceding the first day of the calendar quarter for which
the rate is to be effective, plus 3.5 percent. For this purpose,
calendar quarters begin January 1, April 1, July 1, and October 1.
ARTICLE 16. PROHIBITION ON CERTAIN WAIVERS
SECTION 16.01. Section 406.033, Labor Code, is amended by
adding Subsection (e) to read as follows:
(e) A cause of action described in Subsection (a) may not be
waived by an employee before the employee's injury or death. Any
agreement by an employee to waive a cause of action or any right
described in Subsection (a) before the employee's injury or death
is void and unenforceable.
ARTICLE 17. GENERAL TRANSITION; EFFECTIVE DATE
SECTION 17.01. Except as otherwise provided by this Act, 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 that date 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 17.02. Except as expressly provided, this Act takes
effect immediately if it receives a vote of two-thirds of all the
members elected to each house, as provided by Section 39, Article
III, Texas Constitution. Except as otherwise provided by this Act,
if this Act does not receive the vote necessary for immediate
effect, this Act takes effect September 1, 2001.