Texas 2021 - 87th Regular

Texas House Bill HB4385 Compare Versions

Only one version of the bill is available at this time.

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1	1	87R8037 KKR-F
2	2	By: Patterson H.B. No. 4385
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to medical benefits under the workers' compensation
8	8	system.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Section 1305.053, Insurance Code, is amended to
11	11	read as follows:
12	12	Sec. 1305.053. CONTENTS OF APPLICATION. Each certificate
13	13	application must include:
14	14	(1) a description or a copy of the applicant's basic
15	15	organizational structure documents and other related documents,
16	16	including organizational charts or lists that show:
17	17	(A) the relationships and contracts between the
18	18	applicant and any affiliates of the applicant; and
19	19	(B) the internal organizational structure of the
20	20	applicant's management and administrative staff;
21	21	(2) biographical information regarding each person
22	22	who governs or manages the affairs of the applicant, accompanied by
23	23	information sufficient to allow the commissioner to determine the
24	24	competence, fitness, and reputation of each officer or director of
25	25	the applicant or other person having control of the applicant;
26	26	(3) a copy of the form of any contract between the
27	27	applicant and any provider or group of providers, and with any third
28	28	party performing services on behalf of the applicant under
29	29	Subchapter D;
30	30	(4) a copy of the form of each contract with an
31	31	insurance carrier, as described by Section 1305.154;
32	32	(5) a financial statement, current as of the date of
33	33	the application, that is prepared using generally accepted
34	34	accounting practices and includes:
35	35	(A) a balance sheet that reflects a solvent
36	36	financial position;
37	37	(B) an income statement;
38	38	(C) a cash flow statement; and
39	39	(D) the sources and uses of all funds;
40	40	(6) a statement acknowledging that lawful process in a
41	41	legal action or proceeding against the network on a cause of action
42	42	arising in this state is valid if served in the manner provided by
43	43	Chapter 804 for a domestic company;
44	44	(7) a description and a map of the applicant's service
45	45	area or areas, with key and scale, that identifies each county or
46	46	part of a county to be served;
47	47	(8) a description of programs and procedures to be
48	48	utilized, including:
49	49	(A) a complaint system, as required under
50	50	Subchapter I; and
51	51	(B) a quality improvement program, as required
52	52	under Subchapter G; [and
53	53	[(C) the utilization review program described in
54	54	Subchapter H;]
55	55	(9) a list of all contracted network providers that
56	56	demonstrates the adequacy of the network to provide comprehensive
57	57	health care services sufficient to serve the population of injured
58	58	employees within the service area and maps that demonstrate that
59	59	the access and availability standards under Subchapter G are met;
60	60	and
61	61	(10) any other information that the commissioner
62	62	requires by rule to implement this chapter.
63	63	SECTION 2. Section 1305.154(c), Insurance Code, is amended
64	64	to read as follows:
65	65	(c) A network's contract with a carrier must include:
66	66	(1) a description of the functions that the carrier
67	67	delegates to the network, consistent with the requirements of
68	68	Subsection (b), and the reporting requirements for each function;
69	69	(2) a statement that the network and any management
70	70	contractor or third party to which the network delegates a function
71	71	will perform all delegated functions in full compliance with all
72	72	requirements of this chapter, the Texas Workers' Compensation Act,
73	73	and rules of the commissioner or the commissioner of workers'
74	74	compensation;
75	75	(3) a provision that the contract:
76	76	(A) may not be terminated without cause by either
77	77	party without 90 days' prior written notice; and
78	78	(B) must be terminated immediately if cause
79	79	exists;
80	80	(4) a hold-harmless provision stating that the
81	81	network, a management contractor, a third party to which the
82	82	network delegates a function, and the network's contracted
83	83	providers are prohibited from billing or attempting to collect any
84	84	amounts from employees for health care services under any
85	85	circumstances, including the insolvency of the carrier or the
86	86	network, except as provided by Section 1305.451(b)(6);
87	87	(5) a statement that the carrier retains ultimate
88	88	responsibility for ensuring that all delegated functions and all
89	89	management contractor functions are performed in accordance with
90	90	applicable statutes and rules and that the contract may not be
91	91	construed to limit in any way the carrier's responsibility,
92	92	including financial responsibility, to comply with all statutory
93	93	and regulatory requirements;
94	94	(6) a statement that the network's role is to provide
95	95	the services described under Subsection (b) as well as any other
96	96	services or functions delegated by the carrier, including functions
97	97	delegated to a management contractor, subject to the carrier's
98	98	oversight and monitoring of the network's performance;
99	99	(7) a requirement that the network provide the
100	100	carrier, at least monthly and in a form usable for audit purposes,
101	101	the data necessary for the carrier to comply with reporting
102	102	requirements of the department and the division of workers'
103	103	compensation with respect to any services provided under the
104	104	contract, as determined by commissioner rules;
105	105	(8) a requirement that the carrier, the network, any
106	106	management contractor, and any third party to which the network
107	107	delegates a function comply with the data reporting requirements of
108	108	the Texas Workers' Compensation Act and rules of the commissioner
109	109	of workers' compensation;
110	110	(9) a contingency plan under which the carrier would,
111	111	in the event of termination of the contract or a failure to perform,
112	112	reassume one or more functions of the network under the contract,
113	113	including functions related to:
114	114	(A) payments to providers and notification to
115	115	employees;
116	116	(B) quality of care; and
117	117	(C) [utilization review; and
118	118	[(D)] continuity of care, including a plan for
119	119	identifying and transitioning employees to new providers;
120	120	(10) a provision that requires that any agreement by
121	121	which the network delegates any function to a management contractor
122	122	or any third party be in writing, and that such an agreement require
123	123	the delegated third party or management contractor to be subject to
124	124	all the requirements of this subchapter;
125	125	(11) [a provision that requires the network to provide
126	126	to the department the license number of a management contractor or
127	127	any delegated third party who performs a function that requires a
128	128	license as a utilization review agent under Chapter 4201 or any
129	129	other license under this code or another insurance law of this
130	130	state;
131	131	[(12)] an acknowledgment that:
132	132	(A) any management contractor or third party to
133	133	whom the network delegates a function must perform in compliance
134	134	with this chapter and other applicable statutes and rules, and that
135	135	the management contractor or third party is subject to the
136	136	carrier's and the network's oversight and monitoring of its
137	137	performance; and
138	138	(B) if the management contractor or the third
139	139	party fails to meet monitoring standards established to ensure that
140	140	functions delegated to the management contractor or the third party
141	141	under the delegation contract are in full compliance with all
142	142	statutory and regulatory requirements, the carrier or the network
143	143	may cancel the delegation of one or more delegated functions;
144	144	(12) [(13)] a requirement that the network and any
145	145	management contractor or third party to which the network delegates
146	146	a function provide all necessary information to allow the carrier
147	147	to provide information to employees as required by Section
148	148	1305.451; and
149	149	(13) [(14)] a provision that requires the network, in
150	150	contracting with a third party directly or through another third
151	151	party, to require the third party to permit the commissioner to
152	152	examine at any time any information the commissioner believes is
153	153	relevant to the third party's financial condition or the ability of
154	154	the network to meet the network's responsibilities in connection
155	155	with any function the third party performs or has been delegated.
156	156	SECTION 3. Section 1305.451(b), Insurance Code, is amended
157	157	to read as follows:
158	158	(b) The written description required under Subsection (a)
159	159	must be in English, Spanish, and any additional language common to
160	160	an employer's employees, must be in plain language and in a readable
161	161	and understandable format, and must include, in a clear, complete,
162	162	and accurate format:
163	163	(1) a statement that the entity providing health care
164	164	to employees is a workers' compensation health care network;
165	165	(2) the network's toll-free number and address for
166	166	obtaining additional information about the network, including
167	167	information about network providers;
168	168	(3) a statement that in the event of an injury, the
169	169	employee must select a treating doctor:
170	170	(A) from a list of all the network's treating
171	171	doctors who have contracts with the network in that service area; or
172	172	(B) as described by Section 1305.105;
173	173	(4) a statement that, except for emergency services,
174	174	the employee shall obtain all health care and specialist referrals
175	175	through the employee's treating doctor;
176	176	(5) an explanation that network providers have agreed
177	177	to look only to the network or insurance carrier and not to
178	178	employees for payment of providing health care, except as provided
179	179	by Subdivision (6);
180	180	(6) a statement that if the employee obtains health
181	181	care from non-network providers without network approval, except as
182	182	provided by Section 1305.006, the insurance carrier may not be
183	183	liable, and the employee may be liable, for payment for that health
184	184	care;
185	185	(7) information about how to obtain emergency care
186	186	services, including emergency care outside the service area, and
187	187	after-hours care;
188	188	(8) [a list of the health care services for which the
189	189	insurance carrier or network requires preauthorization or
190	190	concurrent review;
191	191	[(9)] an explanation regarding continuity of
192	192	treatment in the event of the termination from the network of a
193	193	treating doctor;
194	194	(9) [(10)] a description of the network's complaint
195	195	system, including a statement that the network is prohibited from
196	196	retaliating against:
197	197	(A) an employee if the employee files a complaint
198	198	against the network or appeals a decision of the network; or
199	199	(B) a provider if the provider, on behalf of an
200	200	employee, reasonably files a complaint against the network or
201	201	appeals a decision of the network;
202	202	(10) [(11)] a summary of the insurance carrier's or
203	203	network's procedures relating to adverse determinations and the
204	204	availability of the independent review process;
205	205	(11) [(12)] a list of network providers updated at
206	206	least quarterly, including:
207	207	(A) the names and addresses of the providers;
208	208	(B) a statement of limitations of accessibility
209	209	and referrals to specialists; and
210	210	(C) a disclosure of which providers are accepting
211	211	new patients; and
212	212	(12) [(13)] a description of the network's service
213	213	area.
214	214	SECTION 4. Section 4201.054(a), Insurance Code, is amended
215	215	to read as follows:
216	216	(a) This [Except as provided by this section, this] chapter
217	217	does not apply [applies] to [utilization review of] a health care
218	218	service provided to a person eligible for workers' compensation
219	219	medical benefits under Title 5, Labor Code. [The commissioner of
220	220	workers' compensation shall regulate as provided by this chapter a
221	221	person who performs utilization review of a medical benefit
222	222	provided under Title 5, Labor Code.]
223	223	SECTION 5. Section 408.0043(a), Labor Code, is amended to
224	224	read as follows:
225	225	(a) This section applies to a person, other than a
226	226	chiropractor or a dentist, who performs health care services under
227	227	this title as:
228	228	(1) a doctor performing peer review;
229	229	(2) [a doctor performing a utilization review of a
230	230	health care service provided to an injured employee;
231	231	[(3)] a doctor performing an independent review of a
232	232	health care service provided to an injured employee;
233	233	[(4) a designated doctor;
234	234	[(5) a doctor performing a required medical
235	235	examination;] or
236	236	(3) [(6)] a doctor serving as a member of the medical
237	237	quality review panel.
238	238	SECTION 6. Section 408.0044(a), Labor Code, is amended to
239	239	read as follows:
240	240	(a) This section applies to a dentist who performs dental
241	241	services under this title as:
242	242	(1) a doctor performing peer review of dental
243	243	services; or
244	244	(2) [a doctor performing a utilization review of a
245	245	dental service provided to an injured employee;
246	246	[(3)] a doctor performing an independent review of a
247	247	dental service provided to an injured employee[; or
248	248	[(4) a doctor performing a required dental
249	249	examination].
250	250	SECTION 7. Section 408.0045(a), Labor Code, is amended to
251	251	read as follows:
252	252	(a) This section applies to a chiropractor who performs
253	253	chiropractic services under this title as:
254	254	(1) a doctor performing peer review of chiropractic
255	255	services;
256	256	(2) [a doctor performing a utilization review of a
257	257	chiropractic service provided to an injured employee;
258	258	[(3)] a doctor performing an independent review of a
259	259	chiropractic service provided to an injured employee;
260	260	[(4) a designated doctor providing chiropractic
261	261	services;
262	262	[(5) a doctor performing a required medical
263	263	examination;] or
264	264	(3) [(6)] a chiropractor serving as a member of the
265	265	medical quality review panel.
266	266	SECTION 8. Section 408.021(a), Labor Code, is amended to
267	267	read as follows:
268	268	(a) An employee who sustains a compensable injury is
269	269	entitled to all health care reasonably required by the nature of the
270	270	injury as and when needed as determined by the employee's treating
271	271	doctor. The employee is specifically entitled to health care that:
272	272	(1) cures or relieves the effects naturally resulting
273	273	from the compensable injury;
274	274	(2) promotes recovery; or
275	275	(3) enhances the ability of the employee to return to
276	276	or retain employment.
277	277	SECTION 9. Sections 408.0231(b), (c), (e), and (f), Labor
278	278	Code, are amended to read as follows:
279	279	(b) The commissioner by rule shall establish criteria for:
280	280	(1) deleting or suspending a doctor from the list of
281	281	approved doctors; and
282	282	(2) imposing sanctions on a doctor or an insurance
283	283	carrier as provided by this section[;
284	284	[(3) monitoring of utilization review agents, as
285	285	provided by a memorandum of understanding between the division and
286	286	the Texas Department of Insurance; and
287	287	[(4) authorizing increased or reduced utilization
288	288	review and preauthorization controls on a doctor].
289	289	(c) Rules adopted under Subsection (b) are in addition to,
290	290	and do not affect, the rules adopted under Section 415.023(b). The
291	291	criteria for deleting a doctor from the list or for recommending or
292	292	imposing sanctions may include anything the commissioner considers
293	293	relevant, including:
294	294	(1) a sanction of the doctor by the commissioner for a
295	295	violation of Chapter 413 or Chapter 415;
296	296	(2) a sanction by the Medicare or Medicaid program
297	297	for:
298	298	(A) substandard medical care;
299	299	(B) overcharging;
300	300	(C) overutilization of medical services; or
301	301	(D) any other substantive noncompliance with
302	302	requirements of those programs regarding professional practice or
303	303	billing;
304	304	(3) evidence from the division's medical records that
305	305	[the applicable insurance carrier's utilization review practices
306	306	or] the doctor's charges, fees, diagnoses, treatments,
307	307	evaluations, or impairment ratings are substantially different
308	308	from those the commissioner finds to be fair and reasonable based on
309	309	either a single determination or a pattern of practice;
310	310	(4) a suspension or other relevant practice
311	311	restriction of the doctor's license by an appropriate licensing
312	312	authority;
313	313	(5) professional failure to practice medicine or
314	314	provide health care, including chiropractic care, in an acceptable
315	315	manner consistent with the public health, safety, and welfare;
316	316	(6) findings of fact and conclusions of law made by a
317	317	court, an administrative law judge of the State Office of
318	318	Administrative Hearings, or a licensing or regulatory authority; or
319	319	(7) a criminal conviction.
320	320	(e) The commissioner shall act on a recommendation by the
321	321	medical advisor selected under Section 413.0511 and, after notice
322	322	and the opportunity for a hearing, may impose sanctions under this
323	323	section on a doctor or an insurance carrier [or may recommend action
324	324	regarding a utilization review agent]. The commissioner and the
325	325	commissioner of insurance shall enter into a memorandum of
326	326	understanding to coordinate the regulation of insurance carriers
327	327	[and utilization review agents] as necessary to ensure[:
328	328	[(1)] compliance with applicable regulations[; and
329	329	[(2) that appropriate health care decisions are
330	330	reached under this subtitle and under Chapter 4201, Insurance
331	331	Code].
332	332	(f) The sanctions the commissioner may recommend or impose
333	333	under this section include:
334	334	(1) reduction of allowable reimbursement;
335	335	(2) mandatory preauthorization of all or certain
336	336	health care services;
337	337	(3) required peer review monitoring, reporting, and
338	338	audit;
339	339	(4) deletion or suspension from the approved doctor
340	340	list [and the designated doctor list];
341	341	(5) restrictions on appointment under this chapter;
342	342	(6) conditions or restrictions on an insurance carrier
343	343	regarding actions by insurance carriers under this subtitle in
344	344	accordance with the memorandum of understanding adopted under
345	345	Subsection (e); and
346	346	(7) mandatory participation in training classes or
347	347	other courses as established or certified by the division.
348	348	SECTION 10. Section 408.122, Labor Code, is amended to read
349	349	as follows:
350	350	Sec. 408.122. ELIGIBILITY FOR IMPAIRMENT INCOME BENEFITS.
351	351	A claimant may not recover impairment income benefits unless
352	352	evidence of impairment based on an objective clinical or laboratory
353	353	finding exists. A [If the] finding of impairment made by the
354	354	claimant's treating doctor is presumed to be accurate [is made by a
355	355	doctor chosen by the claimant and the finding is contested, a
356	356	designated doctor or a doctor selected by the insurance carrier
357	357	must be able to confirm the objective clinical or laboratory
358	358	finding on which the finding of impairment is based].
359	359	SECTION 11. Section 409.0091(e), Labor Code, is amended to
360	360	read as follows:
361	361	(e) It is not a defense to a subclaim by a health care
362	362	insurer that:
363	363	(1) the subclaimant has not sought reimbursement from
364	364	a health care provider or the subclaimant's insured; or
365	365	(2) [the subclaimant or the health care provider did
366	366	not request preauthorization under Section 413.014 or rules adopted
367	367	under that section; or
368	368	[(3)] the health care provider did not bill the
369	369	workers' compensation insurance carrier, as provided by Section
370	370	408.027, before the 95th day after the date the health care for
371	371	which the subclaimant paid was provided.
372	372	SECTION 12. Section 410.307(b), Labor Code, is amended to
373	373	read as follows:
374	374	(b) If substantial change of condition is disputed, the
375	375	court shall require the employee's treating [designated] doctor in
376	376	the case to verify the substantial change of condition, if any. The
377	377	findings of the treating [designated] doctor shall be presumed to
378	378	be correct, and the court shall base its finding on the medical
379	379	evidence presented by the treating [designated] doctor in regard to
380	380	substantial change of condition unless the preponderance of the
381	381	other medical evidence is to the contrary.
382	382	SECTION 13. Section 413.002(b), Labor Code, is amended to
383	383	read as follows:
384	384	(b) In monitoring [health care providers who serve as
385	385	designated doctors under Chapter 408 and] independent review
386	386	organizations who provide services described by this chapter, the
387	387	division shall evaluate:
388	388	(1) compliance with this subtitle and with rules
389	389	adopted by the commissioner relating to medical policies, fee
390	390	guidelines, treatment guidelines, return-to-work guidelines, and
391	391	impairment ratings; and
392	392	(2) the quality and timeliness of decisions made under
393	393	Section [408.0041, 408.122, 408.151, or] 413.031.
394	394	SECTION 14. Section 413.017, Labor Code, is amended to read
395	395	as follows:
396	396	Sec. 413.017. PRESUMPTION OF REASONABLENESS. Medical [The
397	397	following medical] services provided by a treating doctor are
398	398	presumed to be reasonable[:
399	399	[(1) medical services consistent with the medical
400	400	policies and fee guidelines adopted by the commissioner; and
401	401	[(2) medical services that are provided subject to
402	402	prospective, concurrent, or retrospective review as required by the
403	403	medical policies of the division and that are authorized by an
404	404	insurance carrier].
405	405	SECTION 15. Sections 413.031(a), (e), (e-1), and (h), Labor
406	406	Code, are amended to read as follows:
407	407	(a) A party, including a health care provider, is entitled
408	408	to a review of a medical service provided or for which authorization
409	409	of payment is sought if a health care provider is:
410	410	(1) denied payment or paid a reduced amount for the
411	411	medical service rendered;
412	412	(2) [denied authorization for the payment for the
413	413	service requested or performed if authorization is required or
414	414	allowed by this subtitle or commissioner rules;
415	415	[(3)] ordered by the commissioner to refund a payment
416	416	received; or
417	417	(3) [(4)] ordered to make a payment that was refused
418	418	or reduced for a medical service rendered.
419	419	(e) Except as provided by Subsection [Subsections (d),]
420	420	(f), [and (m),] a review of the medical necessity of a health care
421	421	service provided under this chapter or Chapter 408 shall be
422	422	conducted by an independent review organization under Chapter 4202,
423	423	Insurance Code, in the same manner as reviews of utilization review
424	424	decisions by health maintenance organizations. It is a defense for
425	425	the insurance carrier if the carrier timely complies with the
426	426	decision of the independent review organization.
427	427	(e-1) In performing a review of medical necessity under
428	428	Subsection [(d) or] (e), the independent review organization shall
429	429	consider the division's health care reimbursement policies and
430	430	guidelines adopted under Section 413.011. If the independent review
431	431	organization's decision is contrary to the division's policies or
432	432	guidelines adopted under Section 413.011, the independent review
433	433	organization must indicate in the decision the specific basis for
434	434	its divergence in the review of medical necessity.
435	435	(h) The insurance carrier shall pay the cost of the review
436	436	if the dispute arises in connection with[:
437	437	[(1) a request for health care services that require
438	438	preauthorization under Section 413.014 or commissioner rules under
439	439	that section; or
440	440	[(2)] a treatment plan under Section 413.011(g) or
441	441	commissioner rules under that section.
442	442	SECTION 16. Section 413.0511(b), Labor Code, is amended to
443	443	read as follows:
444	444	(b) The medical advisor shall make recommendations
445	445	regarding the adoption of rules and policies to:
446	446	(1) develop, maintain, and review guidelines as
447	447	provided by Section 413.011, including rules regarding impairment
448	448	ratings;
449	449	(2) review compliance with those guidelines;
450	450	(3) regulate or perform other acts related to medical
451	451	benefits as required by the commissioner;
452	452	(4) impose sanctions or delete doctors from the
453	453	division's list of approved doctors under Section 408.023 for:
454	454	(A) any reason described by Section 408.0231; or
455	455	(B) noncompliance with commissioner rules;
456	456	(5) impose conditions or restrictions as authorized by
457	457	Section 408.0231(f);
458	458	(6) receive, and share with the medical quality review
459	459	panel established under Section 413.0512, confidential
460	460	information, and other information to which access is otherwise
461	461	restricted by law, as provided by Sections 413.0512, 413.0513, and
462	462	413.0514 from the Texas State Board of Medical Examiners, the Texas
463	463	Board of Chiropractic Examiners, or other occupational licensing
464	464	boards regarding a physician, chiropractor, or other type of doctor
465	465	who applies for registration or is registered with the division on
466	466	the list of approved doctors;
467	467	(7) determine minimal modifications to the
468	468	reimbursement methodology and model used by the Medicare system as
469	469	necessary to meet occupational injury requirements; and
470	470	(8) monitor the quality and timeliness of decisions
471	471	made by [designated doctors and] independent review organizations,
472	472	and the imposition of sanctions regarding those decisions.
473	473	SECTION 17. Sections 413.0512(b) and (c), Labor Code, are
474	474	amended to read as follows:
475	475	(b) The agencies that regulate health professionals who are
476	476	licensed or otherwise authorized to practice a health profession
477	477	under Title 3, Occupations Code, and who are involved in the
478	478	provision of health care as part of the workers' compensation
479	479	system in this state shall develop lists of health care providers
480	480	licensed or otherwise regulated by those agencies who have
481	481	demonstrated experience in workers' compensation [or utilization
482	482	review]. The medical advisor shall consider appointing some of the
483	483	members of the medical quality review panel from the names on those
484	484	lists and, when appointing members of the medical quality review
485	485	panel, shall select specialists from various health care specialty
486	486	fields to serve on the panel to ensure that the membership of the
487	487	panel has expertise in a wide variety of health care specialty
488	488	fields. The medical advisor shall also consider nominations for the
489	489	panel made by labor, business, and insurance organizations.
490	490	(c) The medical quality review panel shall recommend to the
491	491	medical advisor:
492	492	(1) appropriate action regarding doctors, other
493	493	health care providers, insurance carriers, [utilization review
494	494	agents,] and independent review organizations; and
495	495	(2) the addition or deletion of doctors from the list
496	496	of approved doctors under Section 408.023[; and
497	497	[(3) the certification, revocation of certification,
498	498	or denial of renewal of certification of a designated doctor under
499	499	Section 408.1225].
500	500	SECTION 18. Section 413.054(a), Labor Code, is amended to
501	501	read as follows:
502	502	(a) A person who performs services for the division as [a
503	503	designated doctor,] an independent medical examiner, a doctor
504	504	performing a medical case review, or a member of a peer review panel
505	505	has the same immunity from liability as the commissioner under
506	506	Section 402.00123.
507	507	SECTION 19. Section 415.0035(a), Labor Code, is amended to
508	508	read as follows:
509	509	(a) An insurance carrier or its representative commits an
510	510	administrative violation if that person:
511	511	(1) fails to submit to the division a settlement or
512	512	agreement of the parties; or
513	513	(2) fails to timely notify the division of the
514	514	termination or reduction of benefits and the reason for that
515	515	action[; or
516	516	[(3) denies preauthorization in a manner that is not
517	517	in accordance with rules adopted by the commissioner under Section
518	518	413.014].
519	519	SECTION 20. Sections 504.053(c) and (d), Labor Code, are
520	520	amended to read as follows:
521	521	(c) If the political subdivision or pool provides medical
522	522	benefits in the manner authorized under Subsection (b)(2), the
523	523	following do not apply:
524	524	(1) [Sections 408.004 and 408.0041, unless use of a
525	525	required medical examination or designated doctor is necessary to
526	526	resolve an issue relating to the entitlement to or amount of income
527	527	benefits under this title;
528	528	[(2)] Subchapter B, Chapter 408, except for Section
529	529	408.021;
530	530	(2) [(3)] Chapter 413, except for Section 413.042; and
531	531	(3) [(4)] Chapter 1305, Insurance Code, except for
532	532	Sections 1305.501, 1305.502, and 1305.503.
533	533	(d) If the political subdivision or pool provides medical
534	534	benefits in the manner authorized under Subsection (b)(2), the
535	535	following standards apply:
536	536	(1) the political subdivision or pool must ensure that
537	537	workers' compensation medical benefits are reasonably available to
538	538	all injured workers of the political subdivision or the injured
539	539	workers of the members of the pool within a designed service area;
540	540	(2) the political subdivision or pool must ensure that
541	541	all necessary health care services are provided in a manner that
542	542	will ensure the availability of and accessibility to adequate
543	543	health care providers, specialty care, and facilities;
544	544	(3) the political subdivision or pool must have an
545	545	internal review process for resolving complaints relating to the
546	546	manner of providing medical benefits, including an appeal to the
547	547	governing body or its designee and appeal to an independent review
548	548	organization;
549	549	(4) the political subdivision or pool must establish
550	550	reasonable procedures for the transition of injured workers to
551	551	contract providers and for the continuity of treatment, including
552	552	notice of impending termination of providers and a current list of
553	553	contract providers;
554	554	(5) the political subdivision or pool shall provide
555	555	for emergency care if an injured worker cannot reasonably reach a
556	556	contract provider and the care is for medical screening or other
557	557	evaluation that is necessary to determine whether a medical
558	558	emergency condition exists, necessary emergency care services
559	559	including treatment and stabilization, and services originating in
560	560	a hospital emergency facility following treatment or stabilization
561	561	of an emergency medical condition;
562	562	(6) [prospective or concurrent review of the medical
563	563	necessity and appropriateness of health care services must comply
564	564	with Article 21.58A, Insurance Code;
565	565	[(7)] the political subdivision or pool shall continue
566	566	to report data to the appropriate agency as required by Title 5 of
567	567	this code and Chapter 1305, Insurance Code; and
568	568	(7) [(8)] a political subdivision or pool is subject
569	569	to the requirements under Sections 1305.501, 1305.502, and
570	570	1305.503, Insurance Code.
571	571	SECTION 21. Section 504.055(b), Labor Code, is amended to
572	572	read as follows:
573	573	(b) This section applies only to a first responder who
574	574	sustains a [serious] bodily injury, as defined by Section 1.07,
575	575	Penal Code, in the course and scope of employment that prevents the
576	576	first responder from performing the full duties assigned to the
577	577	first responder at the time of the injury. For purposes of this
578	578	section, an injury sustained in the course and scope of employment
579	579	includes an injury sustained by a first responder providing
580	580	services on a volunteer basis.
581	581	SECTION 22. The following provisions are repealed:
582	582	(1) Sections 1305.004(a)(19), (27), (28), and (29),
583	583	Insurance Code;
584	584	(2) Section 1305.101(b), Insurance Code;
585	585	(3) Section 1305.153(b), Insurance Code;
586	586	(4) Subchapter H, Chapter 1305, Insurance Code;
587	587	(5) Section 4201.054(b), Insurance Code;
588	588	(6) Sections 401.011(22-a), (38-a), (42-a), and
589	589	(42-b), Labor Code;
590	590	(7) Section 408.004, Labor Code;
591	591	(8) Section 408.0041, Labor Code;
592	592	(9) Section 408.0042, Labor Code;
593	593	(10) Section 408.1225, Labor Code;
594	594	(11) Section 408.125, Labor Code;
595	595	(12) Section 408.151, Labor Code;
596	596	(13) Section 409.0091(d), Labor Code;
597	597	(14) Section 413.014, Labor Code;
598	598	(15) Sections 413.031(d), (g), and (m), Labor Code;
599	599	and
600	600	(16) Section 413.044, Labor Code.
601	601	SECTION 23. The change in law made by this Act applies only
602	602	to a claim for workers' compensation benefits based on a
603	603	compensable injury that occurs on or after the effective date of
604	604	this Act. A claim based on a compensable injury that occurs before
605	605	the effective date of this Act is governed by the law in effect on
606	606	the date the compensable injury occurred, and the former law is
607	607	continued in effect for that purpose.
608	608	SECTION 24. This Act takes effect September 1, 2021.