Current through Reg. 50, No. 13; March 28, 2025
(a) An insurance carrier that establishes or
contracts with a network must deliver to the employer, and the employer or
carrier, as applicable under subsection (g) of this section, must deliver to
the employer's employees in the manner and at the times prescribed by Insurance
Code §
1305.005, concerning
Participation in Network; Notice of Network Requirements:
(1) the notice of network requirements and
employee information required by Insurance Code §
1305.005 and §
1305.451, concerning
Employee Information; Responsibilities of Employee, and this section;
and
(2) the employee acknowledgment
form described by Insurance Code §
1305.005 and this
section.
(b) An employee
who lives within the service area of a network and who is being treated by a
non-network provider for an injury that occurred before the employer's
insurance carrier established or contracted with the network may:
(1) select a network treating doctor from the
list of contracted doctors who contracted with the workers' compensation
network; or
(2) request a doctor
who the employee selected, prior to the injury, as the employee's HMO primary
care physician or provider under Insurance Code Chapter 843, concerning Health
Maintenance Organizations.
(c) The carrier must provide to the employee
all information required by Insurance Code §
1305.451. The notice
must include an employee acknowledgment form and comply with all requirements
under subsections (d) - (i) of this section, as applicable.
(d) The notice of network requirements and
employee acknowledgment form:
(1) must be in
English, Spanish, and any other language common to 10 percent or more of the
employer's employees;
(2) must be
in a readable and understandable format that meets the plain language
requirements under §
10.63 of this title (relating to
Plain Language Requirements); and
(3) may be in an electronic format as long as
a paper version is available upon request.
(e) The insurance carrier and employer may
use an employee acknowledgment form that complies with this section or a sample
acknowledgment form that may be obtained from the department's
website.
(f) The employee
acknowledgment form must include:
(1) a
statement that the employee has received information that describes what the
employee must do to receive health care under workers' compensation
insurance;
(2) a statement that if
the employee is injured on the job and lives in the service area described in
the information, the employee understands that:
(A) the employee:
(i) must select a treating doctor from the
list of doctors who contracted with the workers' compensation network;
or
(ii) ask the employee's HMO
primary care physician to agree to serve as the employee's treating doctor;
and
(iii) must obtain all health
care and specialist referrals for a compensable injury through the treating
doctor except for emergency services;
(B) the network provider will be paid by the
insurance carrier and will not bill the employee for a compensable injury;
and
(C) if the employee seeks
health care, other than emergency care, from someone other than a network
provider without network approval, the insurance carrier may not be liable, and
the employee may be liable, for payment for that health care;
(3) separate lines for the
employee to fill in the date and employee's signature, printed name, and where
the employee lives;
(4) a separate
line that indicates the name of the employer; and
(5) a separate line that indicates the name
of the network.
(g) The
employer must obtain a signed employee acknowledgment form from each employee,
and a carrier required to provide employee information to an employee under
Insurance Code §
1305.103(c),
concerning Treating Doctor; Referrals, and subsection (b) of this section must
obtain a signed employee acknowledgment form from that employee. For purposes
of this subsection, an employer or carrier, as applicable, may obtain an
acknowledgment of the notice required under this section through electronic
means from an employee who makes an electronic signature in accordance with
applicable law.
(h) The notice of
network requirements must comply with Insurance Code §
1305.005 and §
1305.451 and include:
(1) a statement that the entity providing
health care to employees is a certified workers' compensation health care
network;
(2) the network's
toll-free number and address for obtaining additional information about the
network, including information about network providers;
(3) a description and map of the network's
service area, with key and scale, that clearly identifies each county or ZIP
code area or any parts of a county or ZIP code area that are included in the
service area;
(4) a statement that
an employee who does not live within the network's service area may notify the
carrier as described under §
10.62 of this title (relating to
Dispute Resolution for Employee Requirements Related to In-Network
Care);
(5) a statement that an
employee who asserts that he or she does not currently live in the network's
service area may choose to receive all health care services from the network
during the pendency of the insurance carrier's review under §
10.62 of this title and the
pendency of the department's review of a complaint; and the employee may be
liable, and the carrier may not be liable, for payment for health care services
received out of network if it is ultimately determined that the employee lives
in the network's service area;
(6)
a statement that, except for emergency services, the employee must obtain all
health care and specialist referrals through the employee's treating
doctor;
(7) an explanation that
network providers have agreed to look only to the network or insurance carrier
and not to employees for payment of providing health care for a compensable
injury, except as provided by paragraph (8) of this subsection;
(8) a statement that if the employee obtains
health care from non-network providers without network approval, except for
emergency care, the insurance carrier may not be liable, and the employee may
be liable, for payment for that health care;
(9) information about how to obtain emergency
care services, including emergency care outside the service area, and
after-hours care;
(10) a list of
the health care services for which the insurance carrier or network requires
preauthorization or concurrent review;
(11) an explanation regarding continuity of
treatment in the event of the termination from the network of a treating
doctor;
(12) a description of the
network's complaint system, including:
(A) a
statement that an employee must file complaints with the network regarding
dissatisfaction with any aspect of the network's operations or with network
providers;
(B) any deadline for the
filing of complaints, provided that the deadline may not be less than 90 days
after the date of the event or occurrence that is the basis for the
complaint;
(C) a single point of
contact within the network for receipt of complaints, including the address and
email address of the contact; and
(D) a statement that the network is
prohibited from retaliating against:
(i) an
employee, employer, or person acting on behalf of the employee or employer if
the employee, employer, or person acting on behalf of the employee or employer
files a complaint against the network or appeals a decision of the network;
or
(ii) a provider if the provider,
on behalf of an employee, reasonably files a complaint against the network or
appeals a decision of the network; and
(E) a statement explaining how an employee
may file a complaint with the department as described under §
10.122 of this title (relating to
Submitting Complaints to the Department);
(13) a summary of the insurance carrier's or
network's procedures relating to adverse determinations and the availability of
the independent review process;
(14) a list of network providers updated at
least quarterly, including:
(A) the names and
addresses of network providers grouped by specialty. Treating doctors must be
identified and listed separately from specialists. Providers who are authorized
to assess maximum medical improvement and render impairment ratings and
providers who provide a telehealth service, telemedicine medical service, or
teledentistry dental service must be clearly identified;
(B) a statement of limitations of
accessibility and referrals to specialists; and
(C) a disclosure listing which providers are
accepting new patients; and
(15) a statement that, except for
emergencies, the network must arrange for services, including referrals to
specialists, to be accessible to an employee on a timely basis on request and
within the time appropriate to the circumstances and condition of the injured
employee, but not later than 21 days after the date of the request.
(i) An employer or carrier, as
applicable, must deliver the notice of network requirements and acknowledgment
form to the employer's employees, and document:
(1) the method of delivery;
(2) to whom the notice was
delivered;
(3) the location of the
delivery; and
(4) the date or dates
of delivery.
(j) The
failure of an employer or carrier, as applicable, to establish a standardized
process for complying with subsection (i) of this section creates a rebuttable
presumption that the employee has not received the notice of network
requirements and is not subject to network requirements.
(k) A dispute regarding whether an employer
or carrier provided the information required by this section to an employee may
be resolved by requesting a benefit review conference as provided by Chapter
141 of this title (relating to Dispute Resolution--Benefit Review
Conference).
