By: Van de Putte S.B. No. 1322
A BILL TO BE ENTITLED
AN ACT
relating to the provision of durable medical equipment and home
health care services through informal and voluntary networks in the
workers' compensation system; providing penalties.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subsection (f), Section 408.027, Labor Code, is
amended to read as follows:
(f) Except as provided by Section 408.0281 or 408.0284, any
payment made by an insurance carrier under this section shall be in
accordance with the fee guidelines authorized under this subtitle
if the health care service is not provided through a workers'
compensation health care network under Chapter 1305, Insurance
Code, or at a contracted rate for that health care service if the
health care service is provided through a workers' compensation
health care network under Chapter 1305, Insurance Code.
SECTION 2. Subsection (a), Section 408.0282, Labor Code, is
amended to read as follows:
(a) Each informal or voluntary network described by Section
408.0281 or 408.0284 shall, not later than the 30th day after the
date the network is established, report the following information
to the division:
(1) the name of the informal or voluntary network and
federal employer identification number;
(2) an executive contact for official correspondence
for the informal or voluntary network;
(3) a toll-free telephone number by which a health
care provider may contact the informal or voluntary network;
(4) a list of each insurance carrier with whom the
informal or voluntary network contracts, including the carrier's
federal employer identification number; and
(5) a list of, and contact information for, each
entity with which the informal or voluntary network has a contract
or other business relationship that benefits or is entered into on
behalf of an insurance carrier, including an insurance carrier's
authorized agent or a subsidiary or other affiliate of the network.
SECTION 3. Subchapter B, Chapter 408, Labor Code, is
amended by adding Section 408.0284 to read as follows:
Sec. 408.0284. REIMBURSEMENT FOR DURABLE MEDICAL EQUIPMENT
AND HOME HEALTH CARE SERVICES; ADMINISTRATIVE VIOLATION. (a) In
this section:
(1) "Durable medical equipment" includes prosthetics
and orthotic devices and related medical equipment and supplies.
The term does not include:
(A) an object or device that is surgically
implanted, embedded, inserted, or otherwise applied;
(B) related equipment necessary to operate,
program, or recharge the object or device described by Paragraph
(A); or
(C) an intrathecal pump.
(2) "Informal network" means a network that:
(A) is established under a contract between an
insurance carrier or an insurance carrier's authorized agent and a
health care provider for the provision of durable medical equipment
or home health care services; and
(B) includes a specific fee schedule.
(3) "Voluntary network" means a voluntary workers'
compensation health care delivery network established under former
Section 408.0223, as that section existed before repeal by Chapter
265 (House Bill No. 7), Acts of the 79th Legislature, Regular
Session, 2005, by an insurance carrier for the provision of durable
medical equipment or home health care services.
(b) Notwithstanding any provision of Chapter 1305,
Insurance Code, or Section 504.053 of this code, durable medical
equipment and home health care services may be reimbursed in
accordance with the fee guidelines adopted by the commissioner or
at a voluntarily negotiated contract rate in accordance with this
section.
(c) Notwithstanding any other provision of this title or any
provision of Chapter 1305, Insurance Code, an insurance carrier may
pay a health care provider fees for durable medical equipment or
home health care services that are inconsistent with the fee
guidelines adopted by the commissioner only if the carrier or the
carrier's authorized agent has a contract with the health care
provider and that contract includes a specific fee schedule. An
insurance carrier or the carrier's authorized agent may use an
informal or voluntary network to obtain a contractual agreement
that provides for fees different from the fees authorized under the
fee guidelines adopted by the commissioner for durable medical
equipment or home health care services. If a carrier or the
carrier's authorized agent chooses to use an informal or voluntary
network to obtain a contractual fee arrangement, there must be a
contractual arrangement between:
(1) the carrier or authorized agent and the informal
or voluntary network that authorizes the network to contract with
health care providers for durable medical equipment or home health
care services on the carrier's behalf; and
(2) the informal or voluntary network and the health
care provider that includes a specific fee schedule and complies
with the notice requirements of this section.
(d) An informal or voluntary network, or the carrier or the
carrier's authorized agent shall, at least quarterly, notify each
health care provider of any person, other than an injured employee,
to which the network's contractual fee arrangements with the health
care provider are sold, leased, transferred, or conveyed. Notice
to each health care provider:
(1) must include:
(A) the contact information for the network,
including the name, physical address, and toll-free telephone
number at which a health care provider with which the network has a
contract may contact the network; and
(B) in the body of the notice:
(i) the name, physical address, and
telephone number of any person, other than an injured employee, to
which the network's contractual fee arrangement with the health
care provider is sold, leased, transferred, or conveyed; and
(ii) the start date and any end date of the
period during which the network's contractual fee arrangement with
the health care provider is sold, leased, transferred, or conveyed;
and
(2) may be provided:
(A) in an electronic format, if a paper version
is available on request by the division; and
(B) through an Internet website link, but only if
the website:
(i) contains the information described by
Subdivision (1); and
(ii) is updated at least monthly with
current and correct information.
(e) An informal or voluntary network, or the carrier or the
carrier's authorized agent, as appropriate, shall document the
delivery of the notice required under Subsection (d), including the
method of delivery, to whom the notice was delivered, and the date
of delivery. For purposes of Subsection (d), a notice is considered
to be delivered on, as applicable:
(1) the fifth day after the date the notice is mailed
via United States Postal Service; or
(2) the date the notice is faxed or electronically
delivered.
(f) An insurance carrier, or the carrier's authorized agent
or an informal or voluntary network at the carrier's request, shall
provide copies of each contract described by Subsection (c) to the
division on the request of the division. Information included in a
contract under Subsection (c) is confidential and is not subject to
disclosure under Chapter 552, Government Code. Notwithstanding
Subsection (c), the insurance carrier may be required to pay fees in
accordance with the division's fee guidelines if:
(1) the contract:
(A) is not provided to the division on the
division's request;
(B) does not include a specific fee schedule
consistent with Subsection (c); or
(C) does not clearly state that the contractual
fee arrangement is between the health care provider and the named
insurance carrier or the carrier's authorized agent; or
(2) the carrier or the carrier's authorized agent does
not comply with the notice requirements under Subsection (d).
(g) Failure to provide documentation described by
Subsection (e) to the division on the request of the division or
failure to provide notice as required under Subsection (d) creates
a rebuttable presumption in an enforcement action under this
subtitle and in a medical fee dispute under Chapter 413 that a
health care provider did not receive the notice.
(h) An insurance carrier or the carrier's authorized agent
commits an administrative violation if the carrier or agent
violates any provision of this section. Any administrative penalty
assessed under this subsection shall be assessed against the
carrier, regardless of whether the carrier or agent committed the
violation.
(i) Notwithstanding Section 1305.003(b), Insurance Code, in
the event of a conflict between this section and Section 413.016 or
any other provision of Chapter 413 of this code or Chapter 1305,
Insurance Code, this section prevails.
SECTION 4. Each informal or voluntary network described by
Section 408.0284, Labor Code, as added by this Act, that has a
contract between an insurance carrier or an insurance carrier's
authorized agent and a health care provider that is in effect on the
effective date of this Act shall file the report described by
Subsection (a), Section 408.0282, Labor Code, as amended by this
Act, not later than the 30th day after the effective date of this
Act.
SECTION 5. With respect to a contractual agreement that
provides for fees for durable medical equipment or home health care
services that are different from the fees authorized under the fee
guidelines adopted by the commissioner of workers' compensation
under Title 5, Labor Code, and that is entered into after the
effective date of this Act, the notice required under Subsection
(d), Section 408.0284, Labor Code, as added by this Act, shall be
sent not later than the 30th day after the effective date of the
contract, and subsequent notices required under that section shall
be sent on a quarterly basis.
SECTION 6. If any provision of this Act or its application
to any person or circumstance is held invalid, the invalidity does
not affect other provisions or applications of this Act that can be
given effect without the invalid provision or application, and to
this end the provisions of this Act are severable.
SECTION 7. This Act takes effect September 1, 2013.