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Chapter 4.5. Division of Workers' Compensation
Subchapter 1.7

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§10178. Pilot Project Proposal Requirements.

(a) Proposals submitted to the administrative director for final approval shall include all of the following:

(1) A description of the manner in which health care services are to be provided, including the administrative and organizational structure, how each component of the managed care product will be provided, and the standards and procedures under which an employee who selects the exclusive provider of care option will be permitted to change health care service plans.

(2) The business name and tax identification number of the employer or employee, the approximate number and occupations of participating employees, the health care service plan or provider of health care services, and any other parties required in the operation of the proposal. The proposal shall include signed authorization from all necessary parties, other than the employees, confirming their commitment to the plan. In the case of a proposal under which only small employers will participate, the proposal may specify the method by which employers will be selected to participate in lieu of identifying and obtaining commitments from participating employers and identifying the approximate number and occupations of participating employees.

(3) The method whereby employees will be informed of their rights and options under the proposal, including the right to obtain a decision from the Workers' Compensation Appeals Board in the case of disputes over compensation for injuries compensable under Division 4 (commencing with Section 3200) of the Labor Code. Materials to be used for this purpose shall be submitted with the proposal. Materials shall include a description of the dispute resolution process, a description of dependent coverage, a description of the method and frequency of employee choice of health care provider and a description of any other incentives offered to employees by employers to participate in the plan.

(4) The dispute resolution process under the exclusive provider of care option, including the process made available to employees to voluntarily resolve issues subject to the jurisdiction of the appeals board, as well as the process for resolving disputes which are not subject to the jurisdiction of the appeals board.

(5) A description of how dependents will be covered under the proposal, and if co-payments, premium shares, deductibles, or other charges are to be assessed against employers or dependents for non occupational injuries and illness, the amount of such charges and how these charges will be determined and segregated in a manner to assure compliance with subdivision (a) of Section 3751 of the Labor Code.

(6) The method and frequency of employee choice as to whether the employee will receive medical care under an exclusive provider of care option.

(7) A description of any incentives offered by an employer to employees to encourage participation in the exclusive provider of care option.

(8) Verification of agreement to participate executed by an authorized representative of each exclusive or certified bargaining agent which represents employees of the employer.

(9) The method by which any workers' compensation liability of the employer incurred during the pilot project will be paid after an employee's or employer's participation in the pilot project terminates.

(10) An agreement to provide the administrative director, in the form and manner prescribed by the Administrative Director, with information necessary to evaluate the plan and compliance with this subchapter.

(11) An agreement by the participating employers, or by another participating entity on the behalf of these employers, to pay a proportionate share of the cost of the evaluation of the pilot projects approved under this subchapter, based on the number of participating employees. Nothing in this paragraph shall be construed to require participating employers to pay a share of the evaluation cost if other funding sources are authorized by statute and alternative funding is obtained for this purpose.

NOTE: Authority cited: Sections 133, 4612, and 5307.3, Labor Code. Reference: Section 4612, Labor Code.

HISTORY

1. New section filed 8-31-93; operative 8-31-93. Submitted to OAL for printing only pursuant to Government Code section 11351 (Register 93, No. 36).

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