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Amend HB 473 by striking all below the enacting clause and
substituting the following:
SECTION 1. Section 413.011, Labor Code, is amended by
amending Subsection (d) and adding Subsections (d-1) through (d-6)
to read as follows:
(d) Fee guidelines 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 commissioner shall consider the increased security of payment
afforded by this subtitle in establishing the fee guidelines.
(d-1) Notwithstanding Subsections (b) through (d) and
Section 413.016 [or any other provision of this title], an
insurance carrier may pay fees to a health care provider that are
inconsistent with the fee guidelines adopted by the division if the
insurance carrier, or a network under Chapter 1305, Insurance Code,
arranging out-of-network services under Section 1305.006,
Insurance Code, has a contract with the health care provider and
that contract includes a specific fee schedule. An insurance
carrier or the carrier's authorized agent may use an informal or
voluntary network, as those terms are defined by Section 413.0115,
to obtain a contractual agreement that provides for fees different
from the fees authorized under the division's fee guidelines. If a
carrier or the carrier's authorized agent chooses to use an
informal or voluntary network to obtain a contractual fee
arrangement, there must be a contractual arrangement between:
(1) the carrier or authorized agent and the informal
or voluntary network that authorizes the network to contract with
health care providers on the carrier's behalf; and
(2) the informal or voluntary network and the health
care provider that includes a specific fee schedule and complies
with the notice requirements established under Subsection (d-2).
(d-2) An informal or voluntary network, or the carrier or
the carrier's authorized agent, as appropriate, shall notify each
health care provider of any person that is given access to the
network's fee arrangements with that health care provider within
the time and according to the manner provided by commissioner rule.
(d-3) An insurance carrier shall provide copies of each
contract described by Subsection (d-1) to the division on the
request of the division. Information included in a contract under
Subsection (d-1) is confidential and is not subject to disclosure
under Chapter 552, Government Code. For medical fee disputes that
arise regarding non-network and out-of-network care, the division
may request that copies of each contract under which fees are being
paid be submitted to the division for review. Notwithstanding
Subsection (d-1) or Section 1305.153, Insurance Code, the insurance
carrier may be required to pay fees in accordance with the
division's fee guidelines if the contract:
(1) is not provided in a timely manner to the division
on the division's request;
(2) does not include a specific fee schedule
consistent with Subsection (d-1); and
(3) does not:
(A) clearly state that the contractual fee
arrangement is between the health care provider and the named
insurance carrier or the named insurance carrier's authorized
agent; or
(B) comply with the notice requirements under
Subsection (d-2).
(d-4) Notwithstanding this section or any other provision
of this title, an insurance carrier, an insurance carrier's
authorized agent, or a network certified under Chapter 1305,
Insurance Code, arranging for non-network services or
out-of-network services under Section 1305.006, Insurance Code,
may continue to contract with a health care provider to secure
health care for an injured employee for fees that exceed the fees
adopted by the division under this section.
(d-5) The commissioner and the commissioner of insurance
may adopt rules as necessary to implement this section.
(d-6) Subsections (d-1) through (d-3) and this subsection
expire January 1, 2011.
SECTION 2. Subchapter B, Chapter 413, Labor Code, is
amended by adding Section 413.0115 to read as follows:
Sec. 413.0115. REQUIREMENTS FOR CERTAIN VOLUNTARY OR
INFORMAL NETWORKS. (a) In this section:
(1) "Informal network" means a health care provider
network described by Section 413.011(d-1) that:
(A) is established under a contract between an
insurance carrier and health care providers; and
(B) includes a specific fee schedule.
(2) "Voluntary network" means a voluntary workers'
compensation health care delivery network established by an
insurance carrier under former Section 408.0223, as that section
existed before repeal by Chapter 265, Acts of the 79th Legislature,
Regular Session, 2005.
(b) Not later than January 1, 2011, each informal network or
voluntary network must be certified as a workers' compensation
health care network under Chapter 1305, Insurance Code.
(c) Effective September 1, 2007, each informal network and
voluntary network must provide the following information to the
division:
(1) an executive contact for official correspondence
for the network;
(2) a toll-free telephone number by which a health
care provider may contact the informal network or voluntary
network;
(3) a list of each insurance carrier with whom the
network contracts; and
(4) a list of each entity associated with the network
working on behalf of the insurance carrier, including contact
information for each entity.
(d) Each informal network and voluntary network shall
report any changes to the information provided under Subsection (c)
to the division not later than the 30th day after the effective date
of the change.
SECTION 3. (a) Section 413.011(d-4), Labor Code, as added
by this Act, takes effect January 1, 2011.
(b) Except as provided by Subsection (a) of this section,
this Act takes effect September 1, 2007.