Some political subdivisions that self-insure must provide workers’ compensation medical benefits through a certified network when available and practical, and if they use another authorized method they must meet specified service, review, transition, emergency care, reporting, and compliance requirements.
Sec. 504.053. ELECTION. (a) A political subdivision that self-insures either individually or collectively shall provide workers' compensation medical benefits to the injured employees of the political subdivision through a workers' compensation health care network certified under Chapter 1305, Insurance Code, if the governing body of the political subdivision determines that provision of those benefits through a network is available to the employees and practical for the political subdivision. A political subdivision may enter into interlocal agreements and other agreements with other political subdivisions to establish or contract with networks under this section. (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) 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 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 for Sections 1305.502 and 1305.503. (d) If the political subdivision or pool provides medical benefits 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 workers of the political subdivision or the injured workers of the members of the pool within a designed service area; (2) the political subdivision or pool must ensure that all necessary health care services are provided in a manner that will ensure the availability of and accessibility to adequate health care providers, specialty care, and facilities; (3) the political subdivision or pool must have an internal review process for resolving complaints relating to the manner of providing medical benefits, including 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 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 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) prospective or concurrent review of the medical necessity and appropriateness of health care services must comply with Article 21.58A, Insurance Code; (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 subject to the requirements under Sections 1305.502 and 1305.503, Insurance 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; (2) attorney's fees as provided by Section 408.221(c); and (3) attorney's fees as provided by Section 417.003. Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 3.322, eff. September 1, 2005. Amended by: Acts 2017, 85th Leg., R.S., Ch. 310 (S.B. 877), Sec. 1, eff. September 1, 2017. Acts 2019, 86th Leg., R.S., Ch. 701 (S.B. 2551), Sec. 6, eff. June 10, 2019. Acts 2021, 87th Leg., R.S., Ch. 670 (H.B. 1753), Sec. 2, eff. June 15, 2021. Acts 2021, 87th Leg., R.S., Ch. 856 (S.B. 800), Sec. 23, eff. September 1, 2021.