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TITLE 28INSURANCE
PART 1TEXAS DEPARTMENT OF INSURANCE
CHAPTER 10WORKERS' COMPENSATION HEALTH CARE NETWORKS
SUBCHAPTER DNETWORK REQUIREMENTS
RULE §10.60Notice of Network Requirements; Employee Information

(a) An insurance carrier that establishes or contracts with a network shall deliver to the employer, and the employer shall deliver to the employer's employees in the manner and at the times prescribed by Insurance Code §1305.005:

  (1) the notice of network requirements and employee information required by Insurance Code §1305.005 and §1305.451 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, shall select a network treating doctor or request a doctor who the employee selected, prior to the injury, as the employee's HMO primary care physician or provider, upon notification by the carrier that health care services are being provided through the network. The carrier shall provide to the employee all information required by Insurance Code §1305.451. The notice must include an employee acknowledgement form and comply with all requirements under subsections (c) - (h) of this section, as applicable.

(c) 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 subchapter (relating to Plain Language Requirements); and

  (3) may be in an electronic format provided a paper version is available upon request.

(d) The insurance carrier and employer may use:

  (1) an employee acknowledgment form that complies with this section; or

  (2) a sample acknowledgment form that may be obtained from:

    (A) the department's website at www.tdi.state.tx.us; or

    (B) the HMO Division, Mail Code 103-6A, Texas Department of Insurance, P.O. Box 149104, Austin, Texas 78714-9104.

(e) 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.

(f) The employer shall 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) and subsection (b) of this section shall obtain a signed employee acknowledgment form from that employee. For purposes of this subsection, an employer or carrier, as applicable, may obtain an acknowledgement of the notice required under this section through electronic means from an employee who makes an electronic signature in accordance with applicable law.

(g) 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 subchapter (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 subchapter 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 shall 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 e-mail address of the contact; and

    (D) a statement that the network is prohibited from retaliating against:

      (i) an employee if the employee 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 chapter (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 shall be identified and listed separately from specialists. Providers who are authorized to assess maximum medical improvement and render impairment ratings shall 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.

(h) An employer or carrier, as applicable, shall deliver the notice of network requirements and acknowledgment form to the employer's employees and document the method of delivery, to whom the notice was delivered, the location of the delivery, and the date or dates of delivery. The failure of an employer or carrier, as applicable, to establish a standardized process for delivering to an employee a notice of network requirements and acknowledgment form for a network that has a service area in which the employee lives, including documentation of the method of delivery of the notice, to whom the notice was delivered, location of delivery, and the date or dates of delivery, creates a rebuttable presumption that the employee has not received the notice of network requirements and is not subject to network requirements.


Source Note: The provisions of this §10.60 adopted to be effective December 5, 2005, 30 TexReg 8099

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