(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.
