Workers compensation insurance is elective in Texas.
Workers comp insurance generally pays medical bills and helps replace a portion of lost income for a worker who's hurt while doing a job-related task. Work injuries that are typically covered by workers comp range from muscle injuries to broken bones to breathing problems.
Texas workers compensation law stipulates many details of the limits of workers comp payments, who can be exempt from coverage and who must be covered. Below are many of the specifics contained in the workers comp law in Texas. The Texas Department of Insurance also has a page with helpful information.
Who has to be covered by Texas workers comp?
Can any employees opt out of Texas workers compensation with a waiver?
Yes - corporate officers, sole proprietors and children on family farms can.
Is self-insurance for workers comp allowed in Texas?
Yes, for individual employers, groups of employers and political subdivisions. Political subdivisions in Texas are typically the state or a city, county, special district, school district or public agency.
By self-insuring, a business assumes responsibility for paying their own workers comp claims. A self-insured company typically hires a claims service company to handle claims administration and other services.
Are there exclusions for:
Small employers? No.
Agricultural employers? Yes, certain migrant and seasonal workers are subject to the Workers' Compensation Act.
Domestic employers? Yes.
Independent contractors? Yes.
Casual employees? Yes..
Volunteers? Yes.
Professional athletes? Yes.
Texas workers comp medical benefits
Is there a Texas workers comp fee schedule?
Yes.
Fee schedules define payments for surgery, radiology, hospital services, chiropractic care, ambulance service, prescription drugs and other medical services for an injured worker.
Are there limits on medical treatment?
Yes. For claims treated outside of certified healthcare networks, treatment provided in accordance with agency-adopted, evidence-based medical treatment guidelines is presumed reasonable and necessary. Medical treatment provided in excess of, not recommended, or not addressed by the agency-adopted treatment guidelines requires pre-authorization from the insurance carrier. For claims treated in certified healthcare networks, treatment is provided in accordance with evidence-based treatment guidelines selected by the network. Certified networks can develop their own pre-authorization requirements.
Who makes the initial choice of treating physician?
The employee, for non-network claims, can choose any willing provider. For network claims, the employee can choose from a list provided by the network.
Disability payments for workers compensation insurance in Texas
Workers compensation usually pays an employee a some lost wages when they can't work due to a job-related injury. State laws outline certain limits on the length and amount of the disability payment, based on both temporary and permanent disability.
How are temporary total disability (TTD) payments calculated?
70% of the injured employee's pre-injury weekly wage, but, if the employee earns less than $10 per hour, the first 26 weeks are paid at 75% of the statewide average weekly wage (SAWW) and then 70% thereafter.
Weekly minimum: $134
Weekly maximum: $895
Maximum length of TDD benefits: 105 weeks. An exception to this could be made when an extension of maximum medical improvement based on spinal surgery is approved by the Texas Department of Insurance Division of Workers' Compensation.
How are permanent total disability (PTD) payments calculated?
75% of the employee's average weekly wage (AWW), subject to a minimum and maximum.
Weekly minimum: $134
Weekly maximum: $895
Are there cost of living increases for PTD payments? Yes, 3% increase annually based on date of eligibility.
Maximum length of PTD benefits: No maximum.
How are permanent partial disability (PPD) payments calculated?
70% of the average weekly wage (AWW), subject to a minimum and maximum.
Weekly minimum: $134
Weekly maximum: $627
Fatality benefits under Texas workers compensation law
Maximum burial benefit: $10,000
Dependency benefits, weekly minimum / maximum: None / $895
When do children's dependency benefits end? At age 18; age 25 if the child is a student; if child is disabled, benefits can continue until death or until the child no longer has a disability.
Other injuries covered by Texas workers compensation
Mental stress with no physical injury? No.
Cumulative trauma (such as injuries caused by repeated exposure or repetitive motion)? Yes.
Occupational hearing loss? Yes.
Disfigurement? No.
Source: Workers Compensation Research Institute, May 2016 report