HB3914 - 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.

  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.