89R10050 DNC-D

By: Martinez H.B. No. 3914

A BILL TO BE ENTITLED

AN ACT

relating to the health benefit plan coverage of and reimbursement for the treatment of a first responder's injuries sustained within the course and scope of employment.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. Subtitle E, Title 8, Insurance Code, is amended by adding Chapter 1373 to read as follows:

CHAPTER 1373. COVERAGE FOR WORK-RELATED INJURIES

Sec. 1373.001. DEFINITIONS. In this chapter:

(1) "First responder" means:

(A) an individual employed by a political subdivision of this state who is:

(i) a peace officer under Article 2A.001, Code of Criminal Procedure;

(ii) a person licensed under Chapter 773, Health and Safety Code, as an emergency care attendant, emergency medical technician, emergency medical technician-intermediate, emergency medical technician-paramedic, or licensed paramedic; or

(iii) a firefighter subject to certification by the Texas Commission on Fire Protection under Chapter 419, Government Code, whose principal duties are firefighting and aircraft crash and rescue; or

(B) an individual covered under Section 504.012(a), Labor Code, who is providing volunteer services to a political subdivision of this state as:

(i) a volunteer firefighter, without regard to whether the volunteer firefighter is certified under Subchapter D, Chapter 419, Government Code; or

(ii) an emergency medical services volunteer, as defined by Section 773.003, Health and Safety Code.

(2) "Workers' compensation insurance carrier" means an insurance carrier, as that term is defined by Section 401.011, Labor Code.

Sec. 1373.002. APPLICABILITY. (a) This chapter applies only to a health benefit plan that provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or an individual or group evidence of coverage or similar coverage document that is issued by:

(1) an insurance company;

(2) a group hospital service corporation operating under Chapter 842;

(3) a health maintenance organization operating under Chapter 843;

(4) an approved nonprofit health corporation that holds a certificate of authority under Chapter 844;

(5) a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846;

(6) a stipulated premium company operating under Chapter 884;

(7) a fraternal benefit society operating under Chapter 885;

(8) a Lloyd's plan operating under Chapter 941; or

(9) an exchange operating under Chapter 942.

(b) Notwithstanding any other law, this chapter applies to:

(1) a primary care coverage plan under Chapter 1579;

(2) county employee group health benefits provided under Chapter 157, Local Government Code; and

(3) health and accident coverage provided by a risk pool created under Chapter 172, Local Government Code.

(c) Section 1425.001(a)(6) does not limit the applicability of this chapter.

Sec. 1373.003. COVERAGE REQUIRED. (a) A health benefit plan that provides coverage for a first responder may not exclude coverage of the first responder's claim for medical benefits for treatment of an injury, including all health care required to cure or relieve the effects naturally resulting from the injury, because the injury was or may have been sustained in the course and scope of employment as a first responder or because the injury is or might be compensable under workers' compensation insurance coverage.

(b) For purposes of this chapter, an injury sustained in the course and scope of employment includes an injury sustained by a first responder providing services on a volunteer basis.

Sec. 1373.004. REIMBURSEMENT OF CLAIM. (a) A first responder whose claim for workers' compensation medical benefits is denied by the workers' compensation insurance carrier shall provide the health care provider treating the injury with proof of the initial denial.

(b) A health benefit plan issuer shall pay the health care provider the allowed amount under the health benefit plan for services provided to treat the injury, regardless of whether the injury is ultimately determined to be a compensable injury for purposes of the first responder's workers' compensation insurance coverage.

(c) If the workers' compensation insurance carrier, after the initial denial, accepts the workers' compensation claim for the injury, the carrier shall:

(1) completely reimburse the health benefit plan for any amounts paid to a provider for the treatment of the injury; and

(2) reimburse the injured first responder for any copayment or deductible that was paid in connection with treatment for the injury.

SECTION 2. Section 409.0091, Labor Code, is amended by amending Subsection (h) and adding Subsection (h-1) to read as follows:

(h) Except as otherwise provided by Subsection (h-1), for [For] each medical benefit paid, the workers' compensation insurance carrier shall pay to the health care insurer the lesser of the amount payable under the applicable fee guideline as of the date of service or the actual amount paid by the health care insurer. In the absence of a fee guideline for a specific service paid, the amount per service paid by the health care insurer shall be considered in determining a fair and reasonable payment under rules under this subtitle defining fair and reasonable medical reimbursement. The health care insurer may not recover interest as a part of the subclaim.

(h-1) The workers' compensation insurance carrier shall reimburse a health care insurer for the actual amount paid by the health care insurer to a health care provider for the treatment of an injured first responder under Section 1373.003, Insurance Code.

SECTION 3. (a) The division of worker's compensation of the Department of Insurance shall conduct a study regarding the impact of the changes in law made by this Act. The study must include an assessment of:

(1) the efficiency with which health benefit plans provide medical care for injured first responders while awaiting resolution of workers' compensation claims;

(2) the geographic areas where the coverage was successful; and

(3) the health benefit plans that provided coverage to an injured first responder.

(b) Not later than December 1, 2028, the division shall submit to the legislature a written report that includes a summary of the study and any legislative recommendations based on the study.

SECTION 4. Chapter 1373, Insurance Code, as added by this Act, applies only to a health benefit plan that is delivered, issued for delivery, or renewed on or after January 1, 2026.

SECTION 5. This Act takes effect September 1, 2025.