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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 by adding Subsections (a-1) |
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and (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, including group health insurance plans, with minimal |
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modifications to those reimbursement methodologies as necessary to |
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meet occupational injury 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 (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 health facility fees, the commissioner shall |
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adopt the following payment adjustment factors to the Medicare fee |
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schedule: |
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(1) 165 percent for inpatient care; |
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(2) 250 percent for outpatient care; |
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(3) a stop-loss threshold of $50,000; and |
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(4) carve outs for: |
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(A) blood; |
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(B) hyperbaric oxygen; |
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(C) high-cost pharmaceuticals; |
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(D) air ambulance services; |
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(E) implantables; and |
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(F) orthotics and prosthetics. |
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SECTION 2. (a) The change in law made by this Act applies |
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only to a claim for workers' compensation benefits based on a |
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compensable injury that occurs on or after January 1, 2008. A claim |
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based on a compensable injury that occurs before that date is |
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governed by the law in effect on the date that the compensable |
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injury occurred, and the former law is continued in effect for that |
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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 413.011, |
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Labor Code, as amended by this Act, not later than November 1, 2007. |
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SECTION 3. This Act takes effect September 1, 2007. |