By: Carona S.B. No. 1134
A BILL TO BE ENTITLED
AN ACT
relating to the delivery and payment of health care in the workers'
compensation system.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 408.022, Labor Code, is amended by
adding Subsection (f):
(f) Notwithstanding any other provisions of this chapter,
if an insurance carrier has in place an insurance carrier network as
provided in Section 408.0223, and certified by the network and the
employer or carrier pursuant to Section 408.0225, an employee must
receive treatment from a provider participating in the insurance
carrier network. If the medical treatment or service being sought
by an employee is not available from a network provider within 30
miles of the employee's normal place of residence, then the
employee may select a provider who is not participating in the
insurance carrier network. A carrier may grant authorization to
obtain services from a provider who is not part of the insurance
carrier network if the provider agrees to accept the same
reimbursement as would be provided to network providers and to
abide by the same terms and conditions as apply to other providers
participating in the network.
SECTION 2. Section 408.0223, Labor Code, is amended to read
as follows:
(a) In this section, "insurance carrier network" means a
voluntary workers' compensation health care delivery network
established by or contracting with 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, or contracting with voluntary
insurance carrier networks. [if those voluntary insurance carrier
networks. allow selection of doctors as provided by Section
408.022.
[(d) 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, and as
subsequently amended, apply as minimum standards for insurance
carrier networks and are adopted by reference in this section
except to the extent those standards are inconsistent with this
subtitle. The advisory committee, defined in Section 408.0221, may
recommend additional standards for insurance carrier networks that
are no more stringent than the additional standards that the
advisory committee recommends for regional health care delivery
networks pursuant to Section 408.0221(g).
[(e) The Texas Workers' Compensation Commission shall adopt
rules, as necessary, to implement additional standards for
insurance carrier networks.]
(c) No insurance carrier shall utilize or contract with an
insurance carrier network unless the network and the insurance
carrier shall have jointly certified to the Commission that the
network complies with the standards contained in Section 408.0225.
SECTION 3. Section 408, Labor Code, is amended by inserting
a new section, 408.0225:
Sec. 408.0225. Insurance Carrier Network Standards.
(a) An insurance carrier network must include or provide for
each of the following:
(1) a clearly defined geographical service area;
(2) within its geographical service area, a sufficient
number of participating providers necessary to provide all medical
services, including emergency medical services, as can be
reasonably be expected to be required to treat injured employees,
and to provide such services in a timely, effective, and convenient
manner;
(3) a list of all participating providers organized by
location and medical specialty;
(4) provision for obtaining medical services required
by an injured worker that are not available from a participating
provider;
(5) procedures by which an injured worker may request
a change of provider within the network;
(6) methods, resources, and procedures for monitoring
the quality of care provided to injured workers and for identifying
and eliminating inappropriate utilization of medical services;
(7) methods and procedures for resolving disputes
involving reimbursement and the appropriateness and utilization of
medical services;
(8) methods and procedures, including an appeals
process within the network, for selecting and deselecting providers
participating in the network;
(9) methods for certifying the training, experience,
and other credentials of participating network providers;
(10) methods and procedures for executing and managing
contractual agreements between individual providers and the
network
(11) methods by which an injured worker may appeal to
the commission for the review of a network decision regarding the
utilization of medical services, if the issue involved has not been
resolved to the worker's satisfaction 60 days after first notifying
the network that a dispute exists or after the exhaustion of the
network's internal dispute resolution procedures, whichever comes
first; and
(12) methods and procedures for maintaining accurate
and complete information regarding the utilization and cost of
medical services, and for ensuring the privacy and confidentiality
of a worker's personal information.
(b) An insurance carrier network shall not discriminate
against or exclude from participation any category of provider
whose individual members may be authorized to treat injured
workers.
(c) Whenever the participation of a network provider is
being terminated by the network, the provider shall be informed no
later than 30 days prior to the effective date of the termination
and shall be provided, at the time notice is given, a written
explanation for the decision. The affected provider may request a
reconsideration of the network's decision, although such a request
shall not delay the effective date of the decision. If
reconsideration does not result in a reversal of the decision. the
provider may appeal directly to the Commission, which may order
that the provider be reinstated in the network if it determines that
the network's decision was arbitrary or capricious.
(d) Insurance carrier networks and individual providers may
negotiate and agree to alternative prospective or retrospective
reimbursement arrangements in place of medical reimbursement
policies adopted by the commission, and may negotiate and agree
that providers would not be required and may negotiate and agree
that providers would not be required to apply for and be accepted to
the approved doctor list. Such providers shall be recognized by the
commission as eligible to assign impairment ratings and certify
maximum medical improvement and have all other rights and
responsibilities of those providers on the approved doctor list and
would be deemed included on the approved doctor list.
(e) The commission may, at any time, examine the records and
documents of a certified network and carrier in order to verify
compliance with the requirements of this section. If the
commission determines, after an examination, that an insurance
carrier network fails to meet the standards contained in this
section, it may require the network to take immediate steps to meet
the requirements of this section. If, after a period of time
established by the commission, the insurance carrier network has
failed to correct the deficiencies identified in the examination,
then the commission shall decertify the network. Upon
decertification, injured workers who would have been covered by the
network may select the provider who will treat them.
SECTION 5. Section 413.011, Labor Code, is amended by
adding Subsection (h):
(h) Nothing in this section shall prohibit insurance
carrier networks authorized under Section 408.0225 and individual
providers participating in such networks from agreeing to
alternative prospective or retrospective reimbursement
arrangements. Prospective or retrospective reimbursement for
medical services shall be governed by the contractual agreement
between the network and the participating providers.
SECTION 6. This Act takes effect September 1, 2003.