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.