Bill Text: TX HB528 | 2011-2012 | 82nd Legislature | Introduced
NOTE: There are more recent revisions of this legislation. Read Latest Draft
Bill Title: Relating to the provision of pharmaceutical services through informal and voluntary networks in the workers' compensation system; providing an administrative violation.
Spectrum: Bipartisan Bill
Status: (Passed) 2011-06-17 - Effective immediately [HB528 Detail]
Download: Texas-2011-HB528-Introduced.html
Bill Title: Relating to the provision of pharmaceutical services through informal and voluntary networks in the workers' compensation system; providing an administrative violation.
Spectrum: Bipartisan Bill
Status: (Passed) 2011-06-17 - Effective immediately [HB528 Detail]
Download: Texas-2011-HB528-Introduced.html
82R289 KCR-D | ||
By: Solomons | H.B. No. 528 |
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relating to the provision of pharmaceutical services through | ||
informal and voluntary networks in the workers' compensation | ||
system; providing an administrative violation. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. Section 408.027(f), Labor Code, is amended to | ||
read as follows: | ||
(f) Except as provided by Section 408.0281, any [ |
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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. Subchapter B, Chapter 408, Labor Code, is | ||
amended by adding Sections 408.0281 and 408.0282 to read as | ||
follows: | ||
Sec. 408.0281. REIMBURSEMENT FOR PHARMACEUTICAL SERVICES; | ||
ADMINISTRATIVE VIOLATION. (a) In this section: | ||
(1) "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 pharmaceutical services; | ||
and | ||
(B) includes a specific fee schedule. | ||
(2) "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, Acts of the 79th Legislature, Regular Session, 2005, by an | ||
insurance carrier for the provision of pharmaceutical services. | ||
(b) Notwithstanding any provision of Chapter 1305, | ||
Insurance Code, prescription medication or services, as defined by | ||
Section 401.011(19)(E), may be delivered, directly or through a | ||
contract, only in accordance with this section and this title and | ||
may not be delivered through a workers' compensation health care | ||
network under Chapter 1305, Insurance Code. | ||
(c) Notwithstanding any other provision of this title, | ||
including Section 408.028(f), or any provision of Chapter 1305, | ||
Insurance Code, an insurance carrier may pay a health care provider | ||
fees for pharmaceutical services that are inconsistent with the fee | ||
guidelines adopted by the commissioner only if the carrier 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 pharmaceutical 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 pharmaceutical 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, as appropriate, 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 by or on behalf of the carrier. 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 by or on | ||
behalf of the carrier; and | ||
(ii) the start date and any end date of the | ||
period during which 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 by or on | ||
behalf of the carrier; 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 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. | ||
Sec. 408.0282. REQUIREMENTS FOR CERTAIN INFORMAL OR | ||
VOLUNTARY NETWORKS. (a) Each informal or voluntary network | ||
described by Section 408.0281 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 each entity or insurance carrier agent | ||
associated with the informal or voluntary network working on behalf | ||
of the insurance carrier, including contact information for each | ||
entity. | ||
(b) Each informal or voluntary network shall report any | ||
changes to the information provided under Subsection (a) to the | ||
division not later than the 30th day after the effective date of the | ||
change. | ||
(c) An informal or voluntary network shall submit a report | ||
required under this section, including a report of changes required | ||
under Subsection (b), to the division through the division's online | ||
reporting system available through the division's Internet | ||
website. | ||
(d) An informal or voluntary network commits an | ||
administrative violation if the informal or voluntary network | ||
violates any provision of this section. | ||
SECTION 3. Section 1305.101(c), Insurance Code, is amended | ||
to read as follows: | ||
(c) Notwithstanding any other provision of this chapter, | ||
prescription medication or services, as defined by Section | ||
401.011(19)(E), Labor Code, may not, directly or through a | ||
contract, be delivered through a workers' compensation health care | ||
network. Prescription medication and services shall be reimbursed | ||
as provided by Section 408.0281, Labor Code, other provisions of | ||
the Texas Workers' Compensation Act, and applicable rules of the | ||
commissioner of workers' compensation. | ||
SECTION 4. Section 408.028(g), Labor Code, is repealed. | ||
SECTION 5. (a) With respect to a contractual agreement that | ||
provides for fees for pharmaceutical 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 in effect on the effective date of this Act, the notice | ||
required under Section 408.0281(d), Labor Code, as added by this | ||
Act, shall be sent not later than the 30th day after the effective | ||
date of this Act, and subsequent notices required under that | ||
section shall be sent on a quarterly basis. | ||
(b) With respect to a contractual agreement that provides | ||
for fees for pharmaceutical 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 Section 408.0281(d), 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. Each informal or voluntary network described by | ||
Section 408.0281, 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 for the provision of | ||
pharmaceutical services that is in effect on the effective date of | ||
this Act shall file the report described by Section 408.0282(a), | ||
Labor Code, as added by this Act, not later than the 30th day after | ||
the effective date of this Act. | ||
SECTION 7. A contractual agreement between an insurance | ||
carrier and a health care provider that provides for fees for | ||
pharmaceutical services that are different from the fees authorized | ||
under the fee guidelines adopted by the commissioner of workers' | ||
compensation under Title 5, Labor Code, that was in effect on any | ||
date between and including January 1, 2011, and the effective date | ||
of this Act, and that is arranged under a contract with an informal | ||
or voluntary network registered with the division of workers' | ||
compensation of the Texas Department of Insurance under Section | ||
413.0115, Labor Code, is validated and may not be the sole basis of | ||
an enforcement action under Title 5, Labor Code. | ||
SECTION 8. 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 9. This Act takes effect immediately if it receives | ||
a vote of two-thirds of all the members elected to each house, as | ||
provided by Section 39, Article III, Texas Constitution. If this | ||
Act does not receive the vote necessary for immediate effect, this | ||
Act takes effect September 1, 2011. |