Relating to the provision of medical benefits through political subdivision networks under the workers' compensation system.

89(R) HB 4676 - Introduced version - Bill Text

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.