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A BILL TO BE ENTITLED
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AN ACT
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relating to the provision of medical benefits through political |
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subdivision networks 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 504.001, Labor Code, is amended by |
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adding Subdivisions (1-a) and (3-a) to read as follows: |
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(1-a) "Complaint," "independent review," "medical |
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emergency," "mental health emergency," "rural area," "service |
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area," and "utilization review" have the meanings assigned by |
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Section 1305.004, Insurance Code. |
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(3-a) "Political subdivision network" means an |
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organization formed by the political subdivision or pool directly |
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contracting with health care providers or by contracting through a |
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health benefits pool established under Chapter 172, Local |
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Government Code, to provide medical benefits to a political |
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subdivision's injured employees or the injured employees of the |
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members of the pool. |
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SECTION 2. Section 504.053, Labor Code, is amended by |
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amending Subsections (b), (c), (d), and (e) and adding Subsections |
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(f), (g), and (h) to read as follows: |
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(b) If a political subdivision or a pool determines that a |
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workers' compensation health care network certified under Chapter |
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1305, Insurance Code, is not available or practical for the |
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political subdivision or pool, the political subdivision or pool |
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may provide medical benefits to its injured employees or to the |
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injured employees of the members of the pool: |
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(1) in the manner provided by Chapter 408, other than |
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Sections 408.001(b) and (c) and Section 408.002, and by Subchapters |
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B and C, Chapter 413; or |
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(2) through a political subdivision network [by |
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directly contracting with health care providers or by contracting |
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through a health benefits pool established under Chapter 172, Local |
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Government Code]. |
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(c) If the political subdivision or pool provides medical |
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benefits through a political subdivision network as [in the manner] |
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authorized under Subsection (b)(2), the following do not apply: |
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(1) Sections 408.004 and 408.0041, unless use of a |
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required medical examination or designated doctor is necessary to |
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resolve an issue relating to the entitlement to or amount of income |
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benefits under this title; |
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(2) Subchapter B, Chapter 408, except for Section |
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408.021; |
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(3) Chapter 413, except for Section 413.042; and |
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(4) Chapter 1305, Insurance Code, except as otherwise |
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provided by this section [for Sections 1305.501, 1305.502, and |
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1305.503]. |
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(d) If the political subdivision or pool provides medical |
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benefits through a political subdivision network as [in the manner] |
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authorized under Subsection (b)(2), the following standards apply: |
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(1) the political subdivision or pool must ensure that |
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workers' compensation medical benefits are reasonably available to |
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all injured employees [workers] of the political subdivision or the |
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injured employees [workers] of the members of the pool within the |
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political subdivision network's [a designed] service area; |
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(2) the political subdivision or pool must ensure that |
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all necessary health care services are provided in a manner that |
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complies with Section 1305.302, Insurance Code, and that will |
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ensure the availability of and accessibility to a sufficient number |
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of [adequate] health care providers, specialty care, and facilities |
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in both rural and nonrural areas; |
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(3) the political subdivision or pool must have an |
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internal review process for resolving complaints relating to the |
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manner of providing medical benefits, including a process for the |
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notice and appeal of a complaint that complies with Subchapter I, |
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Chapter 1305, Insurance Code [an appeal to the governing body or its |
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designee and appeal to an independent review organization]; |
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(4) the political subdivision or pool must establish |
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reasonable procedures for the transition of injured employees |
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[workers] to contract providers and for the continuity of |
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treatment, including notice of impending termination of providers |
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and a current list of contract providers; |
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(5) the availability and accessibility of care for a |
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medical emergency or a mental health emergency must comply with |
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Section 1305.302, Insurance Code [the political subdivision or pool |
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shall provide for emergency care if an injured worker cannot |
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reasonably reach a contract provider and the care is for medical |
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screening or other evaluation that is necessary to determine |
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whether a medical emergency condition exists, necessary emergency |
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care services including treatment and stabilization, and services |
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originating in a hospital emergency facility following treatment or |
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stabilization of an emergency medical condition]; |
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(6) utilization [prospective or concurrent] review |
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and independent review of the medical necessity and appropriateness |
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of health care services must comply with Chapters 4201 and 4202 |
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[Article 21.58A], Insurance Code, and applicable rules adopted by |
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the commissioner of insurance and the commissioner of workers' |
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compensation; |
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(7) the political subdivision or pool shall continue |
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to report data to the appropriate agency as required by Title 5 of |
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this code and Chapter 1305, Insurance Code; [and] |
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(8) a political subdivision or pool is also subject to |
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the requirements under Subchapters K and L, Chapter 1305 [Sections |
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1305.501, 1305.502, and 1305.503], Insurance Code; and |
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(9) the political subdivision or pool must comply with |
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the employee notice requirements under Sections 1305.005(d)-(h) |
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and 1305.451, Insurance Code, and any dispute regarding an |
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employee's receipt of a required network notice under those |
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sections may be resolved under Chapter 410 of this code. |
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(e) Nothing in this chapter waives sovereign immunity or |
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creates a new cause of action, except that a political subdivision |
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that self-insures either individually or collectively is liable |
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for: |
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(1) sanctions, administrative penalties, and other |
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remedies authorized under Chapter 415; |
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(1-a) sanctions, emergency orders, and administrative |
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penalties as provided under Chapters 82, 83, and 84, Insurance |
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Code; |
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(2) attorney's fees as provided by Section 408.221(c); |
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and |
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(3) attorney's fees as provided by Section 417.003. |
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(f) Nothing in this section requires a political |
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subdivision network to be certified under Chapter 1305, Insurance |
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Code. |
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(g) The commissioner of insurance: |
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(1) shall monitor political subdivision networks to |
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ensure and enforce compliance with this section, the applicable |
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provisions of Chapter 1305, Insurance Code, and commissioner rules; |
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and |
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(2) may impose sanctions, issue emergency orders, and |
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assess administrative penalties as provided under Chapters 82, 83, |
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and 84, Insurance Code, on a political subdivision network for |
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failing to comply with those laws and rules. |
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(h) The commissioner of insurance and the commissioner of |
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workers' compensation may adopt rules as necessary to implement |
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this section. |
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SECTION 3. Subchapter C, Chapter 504, Labor Code, is |
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amended by adding Section 504.0531 to read as follows: |
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Sec. 504.0531. INTENT OF ELECTION TO PROVIDE MEDICAL |
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BENEFITS THROUGH POLITICAL SUBDIVISION NETWORKS. The purpose of |
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Section 504.053 is to: |
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(1) provide political subdivisions or pools options |
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for providing medical benefits to injured employees when a |
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political subdivision determines in good faith that using a network |
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certified under Chapter 1305, Insurance Code, is not available or |
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practical; and |
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(2) ensure that injured employees who receive medical |
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benefits through political subdivision networks: |
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(A) are notified of their rights under a network; |
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and |
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(B) have the same access to and choices for |
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health care as injured employees who receive medical benefits |
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through certified networks under Chapter 1305, Insurance Code. |
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SECTION 4. Section 504.054(a), Labor Code, is amended to |
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read as follows: |
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(a) A party to a medical dispute that remains unresolved |
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after the independent review described by Section 504.053(d)(6) |
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[504.053(d)(3)] is entitled to a contested case hearing. A hearing |
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under this subsection shall be conducted by the division in the same |
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manner as a hearing conducted under Section 413.0311. |
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SECTION 5. Not later than December 31, 2026, the |
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commissioner of insurance shall provide to the legislature a |
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written recommendation on whether political subdivision networks |
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should be required to be certified by the Texas Department of |
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Insurance. |
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SECTION 6. Section 504.053(e), Labor Code, as amended by |
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this Act, applies only to an administrative violation that occurs |
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on or after the effective date of this Act. |
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SECTION 7. This Act takes effect January 1, 2026. |