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.