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A BILL TO BE ENTITLED
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AN ACT
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relating to the provision of pharmaceutical services through |
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informal and voluntary networks in the workers' compensation |
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system; providing an administrative violation. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 408.027(f), Labor Code, is amended to |
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read as follows: |
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(f) Except as provided by Section 408.0281, any [Any] |
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payment made by an insurance carrier under this section shall be in |
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accordance with the fee guidelines authorized under this subtitle |
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if the health care service is not provided through a workers' |
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compensation health care network under Chapter 1305, Insurance |
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Code, or at a contracted rate for that health care service if the |
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health care service is provided through a workers' compensation |
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health care network under Chapter 1305, Insurance Code. |
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SECTION 2. Subchapter B, Chapter 408, Labor Code, is |
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amended by adding Sections 408.0281 and 408.0282 to read as |
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follows: |
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Sec. 408.0281. REIMBURSEMENT FOR PHARMACEUTICAL SERVICES; |
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ADMINISTRATIVE VIOLATION. (a) In this section: |
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(1) "Informal network" means a network that: |
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(A) is established under a contract between an |
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insurance carrier or an insurance carrier's authorized agent and a |
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health care provider for the provision of pharmaceutical services; |
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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 under former |
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Section 408.0223, as that section existed before repeal by Chapter |
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265, Acts of the 79th Legislature, Regular Session, 2005, by an |
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insurance carrier for the provision of pharmaceutical services. |
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(b) Notwithstanding any provision of Chapter 1305, |
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Insurance Code, prescription medication or services, as defined by |
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Section 401.011(19)(E), may be delivered, directly or through a |
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contract, only in accordance with this section and this title and |
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may not be delivered through a workers' compensation health care |
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network under Chapter 1305, Insurance Code. |
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(c) Notwithstanding any other provision of this title, |
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including Section 408.028(f), or any provision of Chapter 1305, |
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Insurance Code, an insurance carrier may pay a health care provider |
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fees for pharmaceutical services that are inconsistent with the fee |
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guidelines adopted by the commissioner only if the carrier has a |
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contract with the health care provider and that contract includes a |
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specific fee schedule. An insurance carrier or the carrier's |
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authorized agent may use an informal or voluntary network to obtain |
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a contractual agreement that provides for fees different from the |
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fees authorized under the fee guidelines adopted by the |
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commissioner for pharmaceutical services. If a carrier or the |
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carrier's authorized agent chooses to use an informal or voluntary |
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network to obtain a contractual fee arrangement, there must be a |
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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 for pharmaceutical services on the carrier's |
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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 of this section. |
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(d) An informal or voluntary network, or the carrier or the |
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carrier's authorized agent, as appropriate, shall, at least |
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quarterly, notify each health care provider of any person, other |
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than an injured employee, to which the network's contractual fee |
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arrangements with the health care provider are sold, leased, |
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transferred, or conveyed by or on behalf of the carrier. Notice to |
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each health care provider: |
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(1) must include: |
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(A) the contact information for the network, |
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including the name, physical address, and toll-free telephone |
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number at which a health care provider with which the network has a |
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contract may contact the network; and |
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(B) in the body of the notice: |
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(i) the name, physical address, and |
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telephone number of any person, other than an injured employee, to |
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which the network's contractual fee arrangement with the health |
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care provider is sold, leased, transferred, or conveyed by or on |
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behalf of the carrier; and |
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(ii) the start date and any end date of the |
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period during which any person, other than an injured employee, to |
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which the network's contractual fee arrangement with the health |
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care provider is sold, leased, transferred, or conveyed by or on |
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behalf of the carrier; and |
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(2) may be provided: |
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(A) in an electronic format, if a paper version |
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is available on request by the division; and |
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(B) through an Internet website link, but only if |
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the website: |
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(i) contains the information described by |
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Subdivision (1); and |
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(ii) is updated at least monthly with |
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current and correct information. |
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(e) An informal or voluntary network, or the carrier or the |
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carrier's authorized agent, as appropriate, shall document the |
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delivery of the notice required under Subsection (d), including the |
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method of delivery, to whom the notice was delivered, and the date |
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of delivery. For purposes of Subsection (d), a notice is considered |
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to be delivered on, as applicable: |
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(1) the fifth day after the date the notice is mailed |
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via United States Postal Service; or |
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(2) the date the notice is faxed or electronically |
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delivered. |
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(f) An insurance carrier shall provide copies of each |
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contract described by Subsection (c) to the division on the request |
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of the division. Information included in a contract under |
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Subsection (c) is confidential and is not subject to disclosure |
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under Chapter 552, Government Code. Notwithstanding Subsection |
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(c), the insurance carrier may be required to pay fees in accordance |
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with the division's fee guidelines if: |
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(1) the contract: |
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(A) is not provided to the division on the |
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division's request; |
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(B) does not include a specific fee schedule |
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consistent with Subsection (c); or |
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(C) does not clearly state that the contractual |
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fee arrangement is between the health care provider and the named |
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insurance carrier or the carrier's authorized agent; or |
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(2) the carrier or the carrier's authorized agent does |
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not comply with the notice requirements under Subsection (d). |
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(g) Failure to provide documentation described by |
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Subsection (e) to the division on the request of the division or |
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failure to provide notice as required under Subsection (d) creates |
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a rebuttable presumption in an enforcement action under this |
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subtitle and in a medical fee dispute under Chapter 413 that a |
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health care provider did not receive the notice. |
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(h) An insurance carrier or the carrier's authorized agent |
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commits an administrative violation if the carrier or agent |
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violates any provision of this section. Any administrative penalty |
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assessed under this subsection shall be assessed against the |
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carrier, regardless of whether the carrier or agent committed the |
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violation. |
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(i) Notwithstanding Section 1305.003(b), Insurance Code, in |
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the event of a conflict between this section and Section 413.016 or |
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any other provision of Chapter 413 of this code or Chapter 1305, |
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Insurance Code, this section prevails. |
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Sec. 408.0282. REQUIREMENTS FOR CERTAIN INFORMAL OR |
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VOLUNTARY NETWORKS. (a) Each informal or voluntary network |
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described by Section 408.0281 shall, not later than the 30th day |
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after the date the network is established, report the following |
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information to the division: |
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(1) the name of the informal or voluntary network and |
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federal employer identification number; |
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(2) an executive contact for official correspondence |
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for the informal or voluntary network; |
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(3) a toll-free telephone number by which a health |
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care provider may contact the informal or voluntary network; |
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(4) a list of each insurance carrier with whom the |
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informal or voluntary network contracts, including the carrier's |
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federal employer identification number; and |
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(5) a list of each entity or insurance carrier agent |
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associated with the informal or voluntary network working on behalf |
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of the insurance carrier, including contact information for each |
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entity. |
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(b) Each informal or voluntary network shall report any |
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changes to the information provided under Subsection (a) to the |
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division not later than the 30th day after the effective date of the |
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change. |
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(c) An informal or voluntary network shall submit a report |
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required under this section, including a report of changes required |
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under Subsection (b), to the division through the division's online |
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reporting system available through the division's Internet |
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website. |
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(d) An informal or voluntary network commits an |
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administrative violation if the informal or voluntary network |
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violates any provision of this section. |
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SECTION 3. Section 1305.101(c), Insurance Code, is amended |
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to read as follows: |
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(c) Notwithstanding any other provision of this chapter, |
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prescription medication or services, as defined by Section |
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401.011(19)(E), Labor Code, may not, directly or through a |
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contract, be delivered through a workers' compensation health care |
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network. Prescription medication and services shall be reimbursed |
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as provided by Section 408.0281, Labor Code, other provisions of |
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the Texas Workers' Compensation Act, and applicable rules of the |
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commissioner of workers' compensation. |
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SECTION 4. Section 408.028(g), Labor Code, is repealed. |
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SECTION 5. (a) With respect to a contractual agreement that |
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provides for fees for pharmaceutical services that are different |
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from the fees authorized under the fee guidelines adopted by the |
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commissioner of workers' compensation under Title 5, Labor Code, |
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and that is in effect on the effective date of this Act, the notice |
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required under Section 408.0281(d), Labor Code, as added by this |
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Act, shall be sent not later than the 30th day after the effective |
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date of this Act, and subsequent notices required under that |
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section shall be sent on a quarterly basis. |
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(b) With respect to a contractual agreement that provides |
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for fees for pharmaceutical services that are different from the |
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fees authorized under the fee guidelines adopted by the |
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commissioner of workers' compensation under Title 5, Labor Code, |
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and that is entered into after the effective date of this Act, the |
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notice required under Section 408.0281(d), Labor Code, as added by |
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this Act, shall be sent not later than the 30th day after the |
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effective date of the contract, and subsequent notices required |
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under that section shall be sent on a quarterly basis. |
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SECTION 6. Each informal or voluntary network described by |
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Section 408.0281, Labor Code, as added by this Act, that has a |
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contract between an insurance carrier or an insurance carrier's |
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authorized agent and a health care provider for the provision of |
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pharmaceutical services that is in effect on the effective date of |
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this Act shall file the report described by Section 408.0282(a), |
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Labor Code, as added by this Act, not later than the 30th day after |
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the effective date of this Act. |
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SECTION 7. A contractual agreement between an insurance |
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carrier and a health care provider that provides for fees for |
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pharmaceutical services that are different from the fees authorized |
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under the fee guidelines adopted by the commissioner of workers' |
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compensation under Title 5, Labor Code, that was in effect on any |
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date between and including January 1, 2011, and the effective date |
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of this Act, and that is arranged under a contract with an informal |
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or voluntary network registered with the division of workers' |
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compensation of the Texas Department of Insurance under Section |
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413.0115, Labor Code, is validated and may not be the sole basis of |
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an enforcement action under Title 5, Labor Code. |
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SECTION 8. If any provision of this Act or its application |
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to any person or circumstance is held invalid, the invalidity does |
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not affect other provisions or applications of this Act that can be |
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given effect without the invalid provision or application, and to |
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this end the provisions of this Act are severable. |
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SECTION 9. This Act takes effect immediately if it receives |
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a vote of two-thirds of all the members elected to each house, as |
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provided by Section 39, Article III, Texas Constitution. If this |
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Act does not receive the vote necessary for immediate effect, this |
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Act takes effect September 1, 2011. |