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