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A BILL TO BE ENTITLED
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AN ACT
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relating to workers' compensation fee guidelines and payment |
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adjustment factors used in conjunction with those guidelines for |
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certain health care services. |
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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 Subsections (a) and (b) and adding Subsections (a-1) and |
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(b-1) to read as follows: |
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(a) The commissioner shall adopt health care reimbursement |
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policies and guidelines that reflect the standardized |
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reimbursement structures found in other health care delivery |
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systems with minimal modifications to those reimbursement |
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methodologies as necessary to meet occupational injury |
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requirements. |
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(a-1) To achieve standardization, the commissioner shall |
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adopt the most current reimbursement methodologies, models, and |
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values or weights used by the federal Centers for Medicare and |
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Medicaid Services, including applicable payment policies relating |
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to coding, billing, and reporting, and may modify documentation |
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requirements as necessary to meet the requirements of Section |
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413.053. |
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(b) In determining the appropriate fees, the commissioner |
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shall also develop one or more conversion factors or other payment |
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adjustment factors taking into account economic indicators in |
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health care and the requirements of Subsections (a-1), (b-1), and |
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[Subsection] (d). The commissioner shall also provide for |
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reasonable fees for the evaluation and management of care as |
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required by Section 408.025(c) and commissioner rules. This |
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section does not adopt the Medicare fee schedule, and the |
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commissioner may not adopt conversion factors or other payment |
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adjustment factors based solely on those factors as developed by |
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the federal Centers for Medicare and Medicaid Services. |
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(b-1) In developing payment adjustment factors under |
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Subsection (b) for hospital fees, the commissioner shall adopt the |
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following payment adjustment factors to the Medicare fee schedule |
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to be used by insurance carriers, other than governmental entities, |
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in contracting with hospitals for the provision of medical |
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benefits: |
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(1) inpatient hospital care shall be paid at 165 |
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percent of the Medicare base payment amount, as established by 42 |
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U.S.C. Section 1395ww and any federal regulation adopted under that |
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law; |
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(2) outpatient hospital care shall be paid at 250 |
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percent of the Medicare base payment amount, as established by 42 |
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U.S.C. Section 1395l(t) and any federal regulation adopted under |
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that law; |
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(3) inpatient or outpatient hospital care that results |
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in billed charges in an amount greater than $50,000, excluding any |
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charges for the costs of implantables, orthotics, or prosthetics, |
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shall be paid at 75 percent of billed charges; |
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(4) blood products, implantables, orthotics, |
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prosthetics, and pharmaceuticals charged at an amount in excess of |
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$250 per dose shall be paid: |
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(A) in addition to any amount paid under |
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Subdivision (1) or (2); and |
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(B) at cost plus 10 percent; and |
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(5) air ambulance services shall be paid: |
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(A) in addition to any amount paid under |
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Subdivision (1), (2), or (4); and |
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(B) at 75 percent of billed charges. |
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SECTION 2. Subchapter B, Chapter 413, Labor Code, is |
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amended by adding Section 413.0121 to read as follows: |
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Sec. 413.0121. REPORT TO LEGISLATURE. Not later than |
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January 1 of each odd-numbered year, the division and the |
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department shall each prepare and submit a report to the governor, |
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the lieutenant governor, the speaker of the house of |
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representatives, and appropriate legislative committees on the fee |
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guidelines adopted under Section 413.011. The report must include: |
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(1) an evaluation of the fee guidelines in effect |
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immediately preceding the date of the report, including |
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consideration of any issues regarding the application of the fee |
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guidelines; and |
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(2) any adjustments or recommendations regarding |
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changes to the fee guidelines proposed to be made by statute or |
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rule. |
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SECTION 3. (a) The change in law made by this Act applies |
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only to health care for a compensable injury that is provided by a |
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health care provider on or after the effective date of this Act. |
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Health care that is provided before that date is governed by the law |
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in effect on the date that the health care was provided, and the |
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former law is continued in effect for that purpose. |
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(b) The commissioner of workers' compensation shall adopt |
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the rules, policies, and guidelines required by Section |
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413.011(b-1), Labor Code, as amended by this Act, not later than |
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November 1, 2007. |
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SECTION 4. This Act takes effect September 1, 2007. |