California Code of Regulations
Title 8 - Industrial Relations
Division 1 - Department of Industrial Relations
Chapter 4.5 - Division of Workers' Compensation
Subchapter 1 - Administrative Director-Administrative Rules
Article 4 - Certification Standards for Health Care Organizations
Section 9771.69 - Workers' Compensation Health Care Contracts
Universal Citation: 8 CA Code of Regs 9771.69
Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(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.
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).
Note: Authority cited: Stats. 1997, Ch. 346 Section 5. Reference: Sections 4600.3, 4500.5 and 4600.6, Labor Code.
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