By Lucio S.B. No. 1514
77R6641 PB-D
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to the use of health care delivery networks to provide
1-3 workers' compensation medical benefits to employees of the Texas
1-4 Department of Transportation.
1-5 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-6 SECTION 1. Chapter 505, Labor Code, is amended by adding
1-7 Subchapter D to read as follows:
1-8 SUBCHAPTER D. USE OF HEALTH CARE DELIVERY NETWORKS
1-9 Sec. 505.101. DEFINITIONS. In this subchapter:
1-10 (1) "Health care delivery network" means a health care
1-11 delivery system in which a managed care organization arranges for
1-12 the provision of health care services directly or indirectly
1-13 through contracts with health care providers.
1-14 (2) "Managed care organization" means a person who is
1-15 authorized or otherwise permitted by law to arrange for or provide
1-16 a managed care plan.
1-17 (3) "Managed care plan" means a plan under which a
1-18 person undertakes to provide, arrange for, pay for, or reimburse
1-19 any part of the cost of health care services. The term does not
1-20 include a plan that indemnifies a person for the cost of health
1-21 care services through insurance.
1-22 Sec. 505.102. IMPLEMENTATION OF HEALTH CARE DELIVERY SYSTEM.
1-23 (a) In accordance with this subchapter and any other applicable
1-24 state law, the department may:
2-1 (1) implement a health care delivery system developed
2-2 under this subchapter that provides health care to employees
2-3 through the use of health care delivery networks; and
2-4 (2) monitor compliance with and take action as
2-5 necessary or appropriate to enforce this subchapter and related
2-6 rules, orders, and decisions of the department or the commission.
2-7 (b) To comply with this subchapter, the department may:
2-8 (1) establish one or more health care delivery
2-9 networks in various regions of this state; or
2-10 (2) implement this subchapter through contractual
2-11 arrangements with managed care organizations.
2-12 (c) Except as prohibited by federal law, the department and
2-13 the Texas Department of Insurance shall share confidential
2-14 information, including financial data, that relates to or affects a
2-15 person that may contract with the department to carry out the
2-16 purposes of this subchapter.
2-17 Sec. 505.103. USE OF HEALTH CARE DELIVERY NETWORKS. (a) The
2-18 Texas Transportation Commission by rule may require the use of
2-19 health care delivery networks under this subchapter to provide
2-20 medical benefits to employees under this chapter.
2-21 (b) The department shall notify its employees of the
2-22 adoption of a health care delivery system and shall periodically
2-23 provide the employees with a list of health care providers who are
2-24 participating members of the participating health care delivery
2-25 networks.
2-26 Sec. 505.104. RULES. (a) The Texas Transportation
2-27 Commission shall adopt rules as necessary or appropriate to carry
3-1 out its functions under this subchapter.
3-2 (b) The commissioner of insurance shall adopt rules as
3-3 necessary or appropriate to carry out the functions of the Texas
3-4 Department of Insurance under Section 505.102.
3-5 Sec. 505.105. DESIGN AND DEVELOPMENT OF HEALTH CARE DELIVERY
3-6 SYSTEM. In developing a health care delivery system under this
3-7 chapter, the department shall, to the extent possible, design the
3-8 system in a manner that:
3-9 (1) improves the health of employees by:
3-10 (A) emphasizing safety and the prevention of
3-11 work-related accidents and occupational diseases; and
3-12 (B) promoting continuity of care;
3-13 (2) ensures that each employee who sustains a
3-14 compensable injury:
3-15 (A) can receive high-quality, comprehensive
3-16 health care services in the employee's local community; and
3-17 (B) is entitled to immediate treatment of the
3-18 injury from a network health care provider without charge to the
3-19 employee and without compliance with any treatment preapproval
3-20 requirement otherwise applicable for treatment of a compensable
3-21 injury;
3-22 (3) enables this state to control the costs associated
3-23 with the workers' compensation program operated under this chapter
3-24 and results in cost savings to this state through delivery of
3-25 health care services through managed care;
3-26 (4) includes methods for ensuring accountability to
3-27 this state for the provision of health care services under the
4-1 workers' compensation program operated under this chapter,
4-2 including methods for financial reporting, quality assurance, and
4-3 utilization review;
4-4 (5) provides a single point of accountability for
4-5 collection of uniform data to assess, compile, and analyze outcome
4-6 quality and cost efficiency;
4-7 (6) requires comparative analyses of compiled data to
4-8 assess the relative value of alternative health care delivery
4-9 systems;
4-10 (7) oversees the procedures for setting capitation and
4-11 health care provider payment rates to ensure the cost-effective
4-12 provision of quality health care; and
4-13 (8) ensures that both private and public health care
4-14 providers and managed care organizations have an opportunity to
4-15 participate in the system.
4-16 Sec. 505.106. AUDITS; MEMORANDUM OF UNDERSTANDING. (a) The
4-17 department shall audit at least biennially each managed care
4-18 organization that contracts with the state under this subchapter.
4-19 (b) A managed care organization audited under Subsection (a)
4-20 is responsible for paying the costs of the audit. The costs of the
4-21 audit may be allowed as a credit against premium taxes paid by the
4-22 managed care organization, except as provided by Section 2, Article
4-23 1.28, Insurance Code.
4-24 (c) The department and the Texas Department of Insurance
4-25 shall enter into a memorandum of understanding to coordinate audits
4-26 of managed care organizations. The memorandum shall:
4-27 (1) identify any information required in a department
5-1 audit that is not customarily required in a Texas Department of
5-2 Insurance audit; and
5-3 (2) establish procedures for initiating and
5-4 distributing the findings of audits of a managed care organization.
5-5 Sec. 505.107. DUTIES OF MANAGED CARE ORGANIZATION;
5-6 CONTRACTUAL PROVISIONS. (a) A managed care organization that
5-7 contracts with the department under this subchapter shall:
5-8 (1) report to the department or the commission, as
5-9 appropriate, all information required by department or commission
5-10 rule, including information necessary to set rates, detect fraud,
5-11 and ensure quality of care; and
5-12 (2) submit annual disclosure statements to the
5-13 department regarding:
5-14 (A) the financial condition of the managed care
5-15 organization; and
5-16 (B) ownership interests in the managed care
5-17 organization.
5-18 (b) The department shall require that each contract between
5-19 a managed care organization and the state under this subchapter:
5-20 (1) state that information provided by a managed care
5-21 organization under this section may be used as necessary to detect
5-22 fraud and abuse; and
5-23 (2) authorize specific penalties for failure to
5-24 provide information required by department or commission rules.
5-25 SECTION 2. Section 505.002(a), Labor Code, is amended to read
5-26 as follows:
5-27 (a) The following provisions of Subtitles A and B apply to
6-1 and are included in this chapter except to the extent that they are
6-2 inconsistent with this chapter:
6-3 (1) Chapter 401, other than Section 401.012, defining
6-4 "employee";
6-5 (2) Chapter 402;
6-6 (3) Chapter 403, other than Sections 403.001-403.005;
6-7 (4) Chapter 405;
6-8 (5) Subchapters B, D, E, and H, Chapter 406, other
6-9 than Sections 406.071-406.073, and 406.075;
6-10 (6) Chapter 408, other than Sections 408.001(b) and
6-11 (c), 408.022, 408.023, and 408.024;
6-12 (7) Chapters 409 and 410;
6-13 (8) Subchapters A and G, Chapter 411, other than
6-14 Sections 411.003 and 411.004;
6-15 (9) Chapters 412-417; and
6-16 (10) Chapter 451.
6-17 SECTION 3. Subchapter B, Chapter 505, Labor Code, is amended
6-18 by adding Section 505.014 to read as follows:
6-19 Sec. 505.014. USE OF HEALTH CARE DELIVERY NETWORK. To
6-20 receive medical benefits under this chapter, an employee may be
6-21 required to use the services of a health care provider who is a
6-22 participating member of a health care delivery network implemented
6-23 under Subchapter D.
6-24 SECTION 4. This Act takes effect September 1, 2001, and
6-25 applies only to a claim for workers' compensation benefits based on
6-26 a compensable injury that occurs on or after January 1, 2002. A
6-27 claim based on a compensable injury that occurs before January 1,
7-1 2002, is governed by the law in effect on the date that the
7-2 compensable injury occurred, and the former law is continued in
7-3 effect for that purpose.