Texas 2011 - 82nd Regular

Texas House Bill HB528 Compare Versions

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1	1	By: Solomons (Senate Sponsor - Van de Putte) H.B. No. 528
2	2	(In the Senate - Received from the House May 5, 2011;
3	3	May 9, 2011, read first time and referred to Committee on State
4	4	Affairs; May 17, 2011, reported favorably by the following vote:
5	5	Yeas 9, Nays 0; May 17, 2011, sent to printer.)
6	6
7	7
8	8	A BILL TO BE ENTITLED
9	9	AN ACT
10	10	relating to the provision of pharmaceutical services through
11	11	informal and voluntary networks in the workers' compensation
12	12	system; providing an administrative violation.
13	13	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
14	14	SECTION 1. Section 408.027(f), Labor Code, is amended to
15	15	read as follows:
16	16	(f) Except as provided by Section 408.0281, any [Any]
17	17	payment made by an insurance carrier under this section shall be in
18	18	accordance with the fee guidelines authorized under this subtitle
19	19	if the health care service is not provided through a workers'
20	20	compensation health care network under Chapter 1305, Insurance
21	21	Code, or at a contracted rate for that health care service if the
22	22	health care service is provided through a workers' compensation
23	23	health care network under Chapter 1305, Insurance Code.
24	24	SECTION 2. Sections 408.028(f) and (g), Labor Code, are
25	25	amended to read as follows:
26	26	(f) Notwithstanding any other provision of this title, the
27	27	commissioner by rule shall adopt a fee schedule for pharmacy and
28	28	pharmaceutical services that will:
29	29	(1) provide reimbursement rates that are fair and
30	30	reasonable;
31	31	(2) assure adequate access to medications and services
32	32	for injured workers; [and]
33	33	(3) minimize costs to employees and insurance
34	34	carriers; and
35	35	(4) take into consideration the increased security of
36	36	payment afforded by this subtitle.
37	37	(g) Section 413.011(d) and the rules adopted to implement
38	38	that subsection do not apply to the fee schedule adopted by the
39	39	commissioner under Subsection (f). [Insurance carriers must
40	40	reimburse for pharmacy benefits and services using the fee schedule
41	41	as developed by this section, or at rates negotiated by contract.]
42	42	SECTION 3. Subchapter B, Chapter 408, Labor Code, is
43	43	amended by adding Sections 408.0281 and 408.0282 to read as
44	44	follows:
45	45	Sec. 408.0281. REIMBURSEMENT FOR PHARMACEUTICAL SERVICES;
46	46	ADMINISTRATIVE VIOLATION. (a) In this section:
47	47	(1) "Informal network" means a network that:
48	48	(A) is established under a contract between an
49	49	insurance carrier or an insurance carrier's authorized agent and a
50	50	health care provider for the provision of pharmaceutical services;
51	51	and
52	52	(B) includes a specific fee schedule.
53	53	(2) "Voluntary network" means a voluntary workers'
54	54	compensation health care delivery network established under former
55	55	Section 408.0223, as that section existed before repeal by Chapter
56	56	265 (H.B. 7), Acts of the 79th Legislature, Regular Session, 2005,
57	57	by an insurance carrier for the provision of pharmaceutical
58	58	services.
59	59	(b) Notwithstanding any provision of Chapter 1305,
60	60	Insurance Code, or Section 504.053 of this code, prescription
61	61	medication or services, as defined by Section 401.011(19)(E):
62	62	(1) may be reimbursed in accordance with the fee
63	63	guidelines adopted by the commissioner or at a contract rate in
64	64	accordance with this section; and
65	65	(2) may not be delivered through:
66	66	(A) a workers' compensation health care network
67	67	under Chapter 1305, Insurance Code; or
68	68	(B) a contract described by Section
69	69	504.053(b)(2).
70	70	(c) Notwithstanding any other provision of this title,
71	71	including Section 408.028(f), or any provision of Chapter 1305,
72	72	Insurance Code, an insurance carrier may pay a health care provider
73	73	fees for pharmaceutical services that are inconsistent with the fee
74	74	guidelines adopted by the commissioner only if the carrier has a
75	75	contract with the health care provider and that contract includes a
76	76	specific fee schedule. An insurance carrier or the carrier's
77	77	authorized agent may use an informal or voluntary network to obtain
78	78	a contractual agreement that provides for fees different from the
79	79	fees authorized under the fee guidelines adopted by the
80	80	commissioner for pharmaceutical services. If a carrier or the
81	81	carrier's authorized agent chooses to use an informal or voluntary
82	82	network to obtain a contractual fee arrangement, there must be a
83	83	contractual arrangement between:
84	84	(1) the carrier or authorized agent and the informal
85	85	or voluntary network that authorizes the network to contract with
86	86	health care providers for pharmaceutical services on the carrier's
87	87	behalf; and
88	88	(2) the informal or voluntary network and the health
89	89	care provider that includes a specific fee schedule and complies
90	90	with the notice requirements of this section.
91	91	(d) An informal or voluntary network, or the carrier or the
92	92	carrier's authorized agent, as appropriate, shall, at least
93	93	quarterly, notify each health care provider of any person, other
94	94	than an injured employee, to which the network's contractual fee
95	95	arrangements with the health care provider are sold, leased,
96	96	transferred, or conveyed. Notice to each health care provider:
97	97	(1) must include:
98	98	(A) the contact information for the network,
99	99	including the name, physical address, and toll-free telephone
100	100	number at which a health care provider with which the network has a
101	101	contract may contact the network; and
102	102	(B) in the body of the notice:
103	103	(i) the name, physical address, and
104	104	telephone number of any person, other than an injured employee, to
105	105	which the network's contractual fee arrangement with the health
106	106	care provider is sold, leased, transferred, or conveyed; and
107	107	(ii) the start date and any end date of the
108	108	period during which any person, other than an injured employee, to
109	109	which the network's contractual fee arrangement with the health
110	110	care provider is sold, leased, transferred, or conveyed; and
111	111	(2) may be provided:
112	112	(A) in an electronic format, if a paper version
113	113	is available on request by the division; and
114	114	(B) through an Internet website link, but only if
115	115	the website:
116	116	(i) contains the information described by
117	117	Subdivision (1); and
118	118	(ii) is updated at least monthly with
119	119	current and correct information.
120	120	(e) An informal or voluntary network, or the carrier or the
121	121	carrier's authorized agent, as appropriate, shall document the
122	122	delivery of the notice required under Subsection (d), including the
123	123	method of delivery, to whom the notice was delivered, and the date
124	124	of delivery. For purposes of Subsection (d), a notice is considered
125	125	to be delivered on, as applicable:
126	126	(1) the fifth day after the date the notice is mailed
127	127	via United States Postal Service; or
128	128	(2) the date the notice is faxed or electronically
129	129	delivered.
130	130	(f) An insurance carrier, or the carrier's authorized agent
131	131	or an informal or voluntary network at the carrier's request, shall
132	132	provide copies of each contract described by Subsection (c) to the
133	133	division on the request of the division. Information included in a
134	134	contract under Subsection (c) is confidential and is not subject to
135	135	disclosure under Chapter 552, Government Code. Notwithstanding
136	136	Subsection (c), the insurance carrier may be required to pay fees in
137	137	accordance with the division's fee guidelines if:
138	138	(1) the contract:
139	139	(A) is not provided to the division on the
140	140	division's request;
141	141	(B) does not include a specific fee schedule
142	142	consistent with Subsection (c); or
143	143	(C) does not clearly state that the contractual
144	144	fee arrangement is between the health care provider and the named
145	145	insurance carrier or the carrier's authorized agent; or
146	146	(2) the carrier or the carrier's authorized agent does
147	147	not comply with the notice requirements under Subsection (d).
148	148	(g) Failure to provide documentation described by
149	149	Subsection (e) to the division on the request of the division or
150	150	failure to provide notice as required under Subsection (d) creates
151	151	a rebuttable presumption in an enforcement action under this
152	152	subtitle and in a medical fee dispute under Chapter 413 that a
153	153	health care provider did not receive the notice.
154	154	(h) An insurance carrier or the carrier's authorized agent
155	155	commits an administrative violation if the carrier or agent
156	156	violates any provision of this section. Any administrative penalty
157	157	assessed under this subsection shall be assessed against the
158	158	carrier, regardless of whether the carrier or agent committed the
159	159	violation.
160	160	(i) Notwithstanding Section 1305.003(b), Insurance Code, in
161	161	the event of a conflict between this section and Section 413.016 or
162	162	any other provision of Chapter 413 of this code or Chapter 1305,
163	163	Insurance Code, this section prevails.
164	164	Sec. 408.0282. REQUIREMENTS FOR CERTAIN INFORMAL OR
165	165	VOLUNTARY NETWORKS. (a) Each informal or voluntary network
166	166	described by Section 408.0281 shall, not later than the 30th day
167	167	after the date the network is established, report the following
168	168	information to the division:
169	169	(1) the name of the informal or voluntary network and
170	170	federal employer identification number;
171	171	(2) an executive contact for official correspondence
172	172	for the informal or voluntary network;
173	173	(3) a toll-free telephone number by which a health
174	174	care provider may contact the informal or voluntary network;
175	175	(4) a list of each insurance carrier with whom the
176	176	informal or voluntary network contracts, including the carrier's
177	177	federal employer identification number; and
178	178	(5) a list of, and contact information for, each
179	179	entity with which the informal or voluntary network has a contract
180	180	or other business relationship that benefits or is entered into on
181	181	behalf of an insurance carrier, including an insurance carrier's
182	182	authorized agent or a subsidiary or other affiliate of the network.
183	183	(b) Each informal or voluntary network shall report any
184	184	changes to the information provided under Subsection (a) to the
185	185	division not later than the 30th day after the effective date of the
186	186	change.
187	187	(c) An informal or voluntary network shall submit a report
188	188	required under this section, including a report of changes required
189	189	under Subsection (b), to the division through the division's online
190	190	reporting system available through the division's Internet
191	191	website.
192	192	(d) An informal or voluntary network commits an
193	193	administrative violation if the informal or voluntary network
194	194	violates any provision of this section.
195	195	SECTION 4. Section 1305.101(c), Insurance Code, is amended
196	196	to read as follows:
197	197	(c) Notwithstanding any other provision of this chapter,
198	198	prescription medication or services, as defined by Section
199	199	401.011(19)(E), Labor Code, may not, directly or through a
200	200	contract, be delivered through a workers' compensation health care
201	201	network. Prescription medication and services shall be reimbursed
202	202	as provided by Section 408.0281, Labor Code, other provisions of
203	203	the Texas Workers' Compensation Act, and applicable rules of the
204	204	commissioner of workers' compensation.
205	205	SECTION 5. (a) With respect to a contractual agreement that
206	206	provides for fees for pharmaceutical services that are different
207	207	from the fees authorized under the fee guidelines adopted by the
208	208	commissioner of workers' compensation under Title 5, Labor Code,
209	209	and that is in effect on the effective date of this Act, the notice
210	210	required under Section 408.0281(d), Labor Code, as added by this
211	211	Act, shall be sent not later than the 30th day after the effective
212	212	date of this Act, and subsequent notices required under that
213	213	section shall be sent on a quarterly basis.
214	214	(b) With respect to a contractual agreement that provides
215	215	for fees for pharmaceutical services that are different from the
216	216	fees authorized under the fee guidelines adopted by the
217	217	commissioner of workers' compensation under Title 5, Labor Code,
218	218	and that is entered into after the effective date of this Act, the
219	219	notice required under Section 408.0281(d), Labor Code, as added by
220	220	this Act, shall be sent not later than the 30th day after the
221	221	effective date of the contract, and subsequent notices required
222	222	under that section shall be sent on a quarterly basis.
223	223	SECTION 6. Each informal or voluntary network described by
224	224	Section 408.0281, Labor Code, as added by this Act, that has a
225	225	contract between an insurance carrier or an insurance carrier's
226	226	authorized agent and a health care provider for the provision of
227	227	pharmaceutical services that is in effect on the effective date of
228	228	this Act shall file the report described by Section 408.0282(a),
229	229	Labor Code, as added by this Act, not later than the 30th day after
230	230	the effective date of this Act.
231	231	SECTION 7. A contractual agreement between an insurance
232	232	carrier and a health care provider that provides for fees for
233	233	pharmaceutical services that are different from the fees authorized
234	234	under the fee guidelines adopted by the commissioner of workers'
235	235	compensation under Title 5, Labor Code, that was in effect on any
236	236	date between and including January 1, 2011, and the effective date
237	237	of this Act, and that is arranged under a contract with an informal
238	238	or voluntary network registered with the division of workers'
239	239	compensation of the Texas Department of Insurance under Section
240	240	413.0115, Labor Code, is validated and may not be the sole basis of
241	241	an enforcement action under Title 5, Labor Code.
242	242	SECTION 8. If any provision of this Act or its application
243	243	to any person or circumstance is held invalid, the invalidity does
244	244	not affect other provisions or applications of this Act that can be
245	245	given effect without the invalid provision or application, and to
246	246	this end the provisions of this Act are severable.
247	247	SECTION 9. This Act takes effect immediately if it receives
248	248	a vote of two-thirds of all the members elected to each house, as
249	249	provided by Section 39, Article III, Texas Constitution. If this
250	250	Act does not receive the vote necessary for immediate effect, this
251	251	Act takes effect September 1, 2011.
252	252	* * * * *