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Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director--Administrative Rules
Article 4. Certification Standards for Health Care Organizations

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§9771.69 Workers' Compensation Health Care Contracts.

(a) All workers' compensation health care contracts and endorsements and amendments shall be printed legibly and shall include at least the following:

(1) The information required to be included on disclosure forms by Section 4600.6(e) of the Code and the information required to be included on disclosure forms by Rule 9771.67.

(2) Definitions of all terms contained in the contract which:

(A) Are defined by the Act, relevant Labor Code provisions, and the Regulations of the Administrative Director.

(B) Require definition in order to be understood by a reasonable person not possessing special knowledge of law, medicine, or organizations;

(C) Specifically describes the eligibility of employees.

(3) Appropriate captions, in boldface type, regarding the provision of workers' compensation health care, consistent with the requirements of the certification standards for health care organizations promulgated by the Administrative Director of the Division of Workers' Compensation of the Department of Industrial Relations (Cal. Code Regs., Tit. 8, Sec. 9770, et seq. ).

(A) A benefit afforded by the contract shall not be subject to any limitation, exclusion, exception, reduction, deductible, or copayment, if any, which renders the benefit illusory.

(4) Provisions relating to cancellation under appropriate caption, in boldface type, which provisions shall include a statement of the time when a notice of cancellation becomes effective.

(5) A provision requiring the organization to provide written notice within a reasonable time to the other party of any termination or breach of contract by, or inability to perform of, any contracting provider if the other party may be materially and adversely affected thereby.

(6) A provision requiring a self-insured employer, group of self-insured employers, or insurer of an employer to mail promptly to each employee a legible, true copy of any notice of cancellation of the organization contract which may be received from the organization and to provide promptly to the organization proof of such mailing and the date thereof.

(7) A provision that (i) the organization is subject to the requirements of the Labor Code, the Regulations of the Administrative Director, and (ii) any provision required to be in the contract by the above shall bind the organization whether or not provided in the contract.

(b) For the purposes of this section:

(1) “Other party” means (A) in the case of a group of self-insured employers, the group representative designated in the contract, and (B) in the case of a self-insured employer or issuer of an employer, the self-insured employer or insurer of an employer and the insured employer.

(2) Any express or implied requirement of notice to the other party, in the context of a contract with a group of self-insured employers, requires notice to the group representative designated in the contract and, with respect to material matters, to the employers and employees under the contract. An organization may fulfill any obligation imposed by this section to notify employers and employees under such contract if the organization provider notice to the group representative designated in the contract, and the contract requires the group representative to disseminate such notice to employers and employees by the next regular communication to the group, but in no event later than 30 days after the receipt thereof.

NOTE

Authority cited: Stats. 1997, Ch. 346, Section 5. Reference: Sections 4600.3, 4500.5 and 4600.6, Labor Code.

HISTORY

1. New section filed 4-15-98; operative 4-15-98. Submitted to OAL for printing only pursuant to Stats. 1997, Ch. 346, Section 5 (Register 98, No. 16).

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