HB4676 - Relating to the provision of medical benefits through political subdivision networks under the workers' compensation system.

  89R9000 KKR-F     By: Turner H.B. No. 4676       A BILL TO BE ENTITLED   AN ACT   relating to the provision of medical benefits through political   subdivision networks under the workers' compensation system.          BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:          SECTION 1.  Section 504.001, Labor Code, is amended by   adding Subdivisions (1-a) and (3-a) to read as follows:                 (1-a)     "Complaint," "independent review," "medical   emergency," "mental health emergency," "rural area," "service   area," and "utilization review" have the meanings assigned by   Section 1305.004, Insurance Code.                 (3-a)     "Political subdivision network" means an   organization formed by the political subdivision or pool directly   contracting with health care providers or by contracting through a   health benefits pool established under Chapter 172, Local   Government Code, to provide medical benefits to a political   subdivision's injured employees or the injured employees of the   members of the pool.          SECTION 2.  Section 504.053, Labor Code, is amended by   amending Subsections (b), (c), (d), and (e) and adding Subsections   (f), (g), and (h) to read as follows:          (b)  If a political subdivision or a pool determines that a   workers' compensation health care network certified under Chapter   1305, Insurance Code, is not available or practical for the   political subdivision or pool, the political subdivision or pool   may provide medical benefits to its injured employees or to the   injured employees of the members of the pool:                (1)  in the manner provided by Chapter 408, other than   Sections 408.001(b) and (c) and Section 408.002, and by Subchapters   B and C, Chapter 413; or                (2)   through a political subdivision network  [ by   directly contracting with health care providers or by contracting   through a health benefits pool established under Chapter 172, Local   Government Code ].          (c)  If the political subdivision or pool provides medical   benefits through a political subdivision network as [ in the manner ]   authorized under Subsection (b)(2), the following do not apply:                (1)  Sections 408.004 and 408.0041, unless use of a   required medical examination or designated doctor is necessary to   resolve an issue relating to the entitlement to or amount of income   benefits under this title;                (2)  Subchapter B, Chapter 408, except for Section   408.021;                (3)  Chapter 413, except for Section 413.042; and                (4)  Chapter 1305, Insurance Code, except as otherwise   provided by this section [ for Sections 1305.501, 1305.502, and   1305.503 ].          (d)  If the political subdivision or pool provides medical   benefits through a political subdivision network as [ in the manner ]   authorized under Subsection (b)(2), the following standards apply:                (1)  the political subdivision or pool must ensure that   workers' compensation medical benefits are reasonably available to   all injured employees [ workers ] of the political subdivision or the   injured employees [ workers ] of the members of the pool within the   political subdivision network's [ a designed ] service area;                (2)  the political subdivision or pool must ensure that   all necessary health care services are provided in a manner that   complies with Section 1305.302, Insurance Code, and that will   ensure the availability of and accessibility to a sufficient number   of [ adequate ] health care providers, specialty care, and facilities   in both rural and nonrural areas ;                (3)  the political subdivision or pool must have an   internal review process for resolving complaints relating to the   manner of providing medical benefits, including a process for the   notice and appeal of a complaint that complies with Subchapter I,   Chapter 1305, Insurance Code [ an appeal to the governing body or its   designee and appeal to an independent review organization ];                (4)  the political subdivision or pool must establish   reasonable procedures for the transition of injured employees   [ workers ] to contract providers and for the continuity of   treatment, including notice of impending termination of providers   and a current list of contract providers;                (5)   the availability and accessibility of care for a   medical emergency or a mental health emergency must comply with   Section 1305.302, Insurance Code [ the political subdivision or pool   shall provide for emergency care if an injured worker cannot   reasonably reach a contract provider and the care is for medical   screening or other evaluation that is necessary to determine   whether a medical emergency condition exists, necessary emergency   care services including treatment and stabilization, and services   originating in a hospital emergency facility following treatment or   stabilization of an emergency medical condition ];                (6)   utilization [ prospective or concurrent ] review   and independent review of the medical necessity and appropriateness   of health care services must comply with Chapters 4201 and 4202   [ Article 21.58A ], Insurance Code , and applicable rules adopted by   the commissioner of insurance and the commissioner of workers'   compensation ;                (7)  the political subdivision or pool shall continue   to report data to the appropriate agency as required by Title 5 of   this code and Chapter 1305, Insurance Code; [ and ]                (8)  a political subdivision or pool is also subject to   the requirements under Subchapters K and L, Chapter 1305 [ Sections   1305.501, 1305.502, and 1305.503 ], Insurance Code ; and                 (9)     the political subdivision or pool must comply with   the employee notice requirements under Sections 1305.005(d)-(h)   and 1305.451, Insurance Code, and any dispute regarding an   employee's receipt of a required network notice under those   sections may be resolved under Chapter 410 of this code .          (e)  Nothing in this chapter waives sovereign immunity or   creates a new cause of action, except that a political subdivision   that self-insures either individually or collectively is liable   for:                (1)  sanctions, administrative penalties, and other   remedies authorized under Chapter 415;                 (1-a)     sanctions, emergency orders, and administrative   penalties as provided under Chapters 82, 83, and 84, Insurance   Code;                (2)  attorney's fees as provided by Section 408.221(c);   and                (3)  attorney's fees as provided by Section 417.003.           (f)     Nothing in this section requires a political   subdivision network to be certified under Chapter 1305, Insurance   Code.           (g)  The commissioner of insurance:                 (1)     shall monitor political subdivision networks to   ensure and enforce compliance with this section, the applicable   provisions of Chapter 1305, Insurance Code, and commissioner rules;   and                 (2)     may impose sanctions, issue emergency orders, and   assess administrative penalties as provided under Chapters 82, 83,   and 84, Insurance Code, on a political subdivision network for   failing to comply with those laws and rules.           (h)     The commissioner of insurance and the commissioner of   workers' compensation may adopt rules as necessary to implement   this section.          SECTION 3.  Subchapter C, Chapter 504, Labor Code, is   amended by adding Section 504.0531 to read as follows:           Sec.   504.0531.     INTENT OF ELECTION TO PROVIDE MEDICAL   BENEFITS THROUGH POLITICAL SUBDIVISION NETWORKS. The purpose of   Section 504.053 is to:                 (1)     provide political subdivisions or pools options   for providing medical benefits to injured employees when a   political subdivision determines in good faith that using a network   certified under Chapter 1305, Insurance Code, is not available or   practical; and                 (2)     ensure that injured employees who receive medical   benefits through political subdivision networks:                       (A)     are notified of their rights under a network;   and                       (B)     have the same access to and choices for   health care as injured employees who receive medical benefits   through certified networks under Chapter 1305, Insurance Code.          SECTION 4.  Section 504.054(a), Labor Code, is amended to   read as follows:          (a)  A party to a medical dispute that remains unresolved   after the independent review described by Section 504.053(d)(6)   [ 504.053(d)(3) ] is entitled to a contested case hearing.  A hearing   under this subsection shall be conducted by the division in the same   manner as a hearing conducted under Section 413.0311.          SECTION 5.  Not later than December 31, 2026, the   commissioner of insurance shall provide to the legislature a   written recommendation on whether political subdivision networks   should be required to be certified by the Texas Department of   Insurance.          SECTION 6.  Section 504.053(e), Labor Code, as amended by   this Act, applies only to an administrative violation that occurs   on or after the effective date of this Act.          SECTION 7.  This Act takes effect January 1, 2026.