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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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§9779.3. Obligations of Employer Covered by a Contract with a Health Care Organization

(a) When an insurer or employers, a group of self-insured employers, or self-insured employers have contracted with a health care organization certified pursuant to Section 4600.5 of the Labor Code the employer shall provide information to all employees who are eligible to be enrolled in the health care organization as follows:

(1) a new employee shall be provided with the choice of enrolling in an HCO or designating the employee's own personal physician or personal chiropractor no later than 30 days following the employee's date of hire.

(2) a current employee shall be provided with the choice of enrolling in an HCO or designating the employee's own personal physician or personal chiropractor no later than 30 days before the initial enrollment period ends;

(3) an employer must provide information concerning the HCO it is offering to its employees no later than 30 days prior to the final date for enrollment. Information shall be provided in written form, in no less than twelve (12) point typeface, and in a language understandable to employees. The information provided must include, at a minimum, the following:

(i) the name of the HCO offered;

(ii) the corporate or business name of all entities which own or control the HCO offered; and indication of relationship, if any, of the HCO to workers' compensation carrier or self-insured employer;

(iii) the services offered by the HCO;

(iv) a complete listing of all primary treating physicians, specialist physicians, and clinics participating in the HCO who would be reasonably accessible to the employee for the provision of occupational health services. Primary treating physicians who are not accepting new patients must be clearly identified;

(v) If the HCO is also the provider of group health coverage for non-occupational health services, the HCO policy regarding enrollees' ability to use their personal physician (for non-occupational health services) for treatment of work injuries.

(vi) any provider risk-sharing arrangements related to utilization of services.

(4) Within fifteen days following enrollment, the HCO must provide to each enrollee complete information regarding HCO services and processes, including but not limited to:

(i) the services offered, including interpreters services, how such services are obtained, hours of services;

(ii) the definition of emergency care, how to obtain out-of-service treatment, how to obtain after-hours services;

(iii) case management and medical management processes, selection of the primary treating physician, and method for obtaining second opinions, change of physician, or referrals to chiropractors, physical therapists, or specialists;

(iv) the grievance and dispute resolution procedures;

(v) additional services offered, including return to work, health and safety, patient assistance, and patient education.

(b) Employees shall designate their enrollment option on form DWC 1194. This form must be maintained in the employee's personnel file for a minimum of three (3) years, and be made available to the employee or employee's representative on request.

Employees who designate on form DWC 1194 that they do not wish to enroll in an HCO and wish to pre-designate their own personal physician or personal chiropractor or personal acupuncturist shall pre-designate that personal physician or personal chiropractor or personal acupuncturist on the form 1194. At least once each year the employer shall provide the employee with a notice informing the employee of his or her right to continue as an enrollee of the HCO, change to another HCO if another HCO is offered by the employer, or designate the employee's own personal physician, personal chiropractor or personal acupuncturist instead of the HCO. If another HCO is offered by the employer and the employee chooses to change to another HCO, or if the employee chooses to designate a personal physician, personal chiropractor or personal acupuncturist, the employee shall designate such choice on a form DWC 1194, which shall be provided by the employer.

NOTE

Authority cited: Sections 133, 4600.3, 4600.5, 4603.5 and 5307.3, Labor Code. Reference: Sections 4600, 4600.3 and 4600.5, Labor Code.

HISTORY

1. New section filed 3-27-95; operative 3-27-95. Submitted to OAL for printing only pursuant to Government Code section 11351 (Register 95, No. 13).

2. Amendment filed 5-17-99; operative 5-17-99 pursuant to Government Code section 11343.4(d) (Register 99, No. 21).

3. Amendment of section heading and section filed 1-9-2003; operative 1-9-2003 pursuant to Government Code section 11343.4 (Register 2003, No. 2).

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