Bill Text: CA SB764 | 2009-2010 | Regular Session | Amended
Bill Title: Workers' compensation: health care organizations.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced - Dead) 2010-02-01 - Returned to Secretary of Senate pursuant to Joint Rule 56. [SB764 Detail]
Download: California-2009-SB764-Amended.html
BILL NUMBER: SB 764 AMENDED
BILL TEXT
AMENDED IN SENATE APRIL 22, 2009
INTRODUCED BY Senator Negrete McLeod
FEBRUARY 27, 2009
An act to amend Sections 4600.3, 4600.5, and 4600.7 of the Labor
Code, relating to workers' compensation.
LEGISLATIVE COUNSEL'S DIGEST
SB 764, as amended, Negrete McLeod. Workers' compensation: health
care organizations.
(1) Existing law establishes a workers' compensation system,
administered by the Administrative Director of the Division of
Workers Compensation, to compensate an employee for injuries
sustained in the course of his or her employment.
Existing law requires an employer to provide medical services to
an injured worker and permits employers to enter into contracts for
the provision of these medical services with a health care
organization that has been certified by the administrative director
for this purpose.
Existing law relating to services provided by a health care
organization provides for the predesignation of a physician by an
employee, and requires employers who contract with a health care
organization to notify an employee regarding the effect of his or her
election to be treated by the health care organization.
This bill would conform these provisions to those applicable to
employers who have not entered into a contract with a health care
organization for the provision of medical services, as specified.
(2) Existing law requires each application for certification as a
workers' compensation health care organization to be accompanied by a
reasonable fee, prescribed by the administrative director,
sufficient to cover the actual costs of processing the application.
This bill would delete this requirement.
(3) Existing law requires a health care service plan, disability
insurer, workers' compensation insurer, third-party administrator, or
any other entity determined by the administrative director to have
met certain requirements, and that has been deemed to be a workers'
compensation health care organization, to propose a timely and
accurate method to meet the administrative director's requirements
for all carriers of workers' compensation coverage to report
necessary information, as specified.
This bill would delete the specified description of the necessary
information.
(4) Existing law establishes the Workers' Compensation Managed
Care Fund containing fees charged to certified health care
organizations and applicants for purposes of funding the cost of
administration of certification and to repay amounts received as a
loan from the General Fund.
This bill would delete the fund's purpose of funding the cost of
administration of certification.
Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: no.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 4600.3 of the Labor Code is amended to read:
4600.3. (a) (1) Subject to the right provided pursuant to
subdivision (d) of Section 4600, but notwithstanding subdivision (c)
of Section 4600, when a self-insured employer, group of self-insured
employers, or the insurer of an employer contracts with a health care
organization certified pursuant to Section 4600.5 for health care
services required by this article to be provided to injured
employees, those employees who are subject to the contract shall
receive medical services in the manner prescribed in the contract.
(2) Each contract described in paragraph (1) shall comply with the
certification standards provided in Section 4600.5, and shall
provide all medical, surgical, chiropractic, acupuncture, and
hospital treatment, including nursing, medicines, medical and
surgical supplies, crutches, and apparatus, including artificial
members, that is reasonably required to cure or relieve the effects
of the injury, as required by this division, without any payment by
the employee of deductibles, copayments, or any share of the premium.
However, an employee may receive immediate emergency medical
treatment that is compensable from a medical service or health care
provider who is not a member of the health care organization.
(3) Insured employers, a group of self-insured employers, or
self-insured employers who contract with a health care organization
for medical services shall give notice to employees of eligible
medical service providers and any other information regarding the
contract and manner of receiving medical services as the
administrative director may prescribe.
(b) Notwithstanding subdivision (a), no employer that is required
to bargain with an exclusive or certified bargaining agent that
represents employees of the employer in accordance with state or
federal employer-employee relations law shall contract with a health
care organization for purposes of Section 4600.5 with regard to
employees whom the bargaining agent is recognized or certified to
represent for collective bargaining purposes pursuant to state or
federal employer-employee relations law unless authorized to do so by
mutual agreement between the bargaining agent and the employer. If
the collective bargaining agreement is subject to the National Labor
Relations Act (29 U.S.C. Secs. 161 et seq.), the employer may
contract with a health care organization for purposes of Section
4600.5 at any time when the employer and bargaining agent have
bargained to impasse to the extent required by federal law.
(c) (1) When an employee is not receiving or is not eligible to
receive health care coverage for nonoccupational injuries or
illnesses provided by the employer, if 90 days or more
from the date the injury is reported, the employee who has
been receiving treatment from a health care organization or his
or her physician, chiropractor, acupuncturist, or other agent
notifies his or her employer in writing that he or she desires to
stop treatment by the health care organization, the
selection of a physician to provide further medical treatment shall
be made in accordance with subdivision (c) of Section 4600, except
that the employee may in that event designate his or her personal
physician to provide further medical treatment in accordance with
subdivision (d) of Section 4600 in all respects other than the
condition that the employee notified the employer of prior to the
date of injury. he or she shall have the right to be
treated by a physician, chiropractor, or acupuncturist or at a
facility of his or her own choosing within a reasonable geographic
area.
(2) When an employee is receiving or is eligible to receive health
care coverage for nonoccupational injuries or illnesses provided by
the employer, if 180 days or more from the date the injury
is reported, the employee who has been receiving treatment from a
health care organization notifies his or her employer in writing that
he or she desires to stop treatment by the health care organization,
the selection of a physician to provide further medical treatment
shall be in accordance with subdivision (c) of Section 4600, except
that the employee may, at any time 180 days or more from the date the
injury is reported, designate his or her personal physician to
provide further medical treatment in accordance with subdivision (d)
of Section 4600 in all respects other than the condition that the
employee notified the employer of prior to the date of injury.
and has agreed to receive care for occupational
injuries and illnesses from a health care organization provided by
the employer, the employee may be treated for occupational injuries
and diseases by a physician, chiropractor, or
acupuncturist of his or her own choice or at a facility of his or her
own choice within a reasonable geographic area if the employee or
his or her physician, chiropractor, acupuncturist, or other agent
notifies his or her employer in writing only after 180 days from the
date the injury was reported, or upon the date of contract renewal or
open enrollment of the health care organization, whichever occurs
first, but in no case until 90 days from the date the injury was
reported.
(3) For purposes of this subdivision, an employer shall be deemed
to provide health care coverage for nonoccupational injuries and
illnesses if the employer pays more than one-half the costs of the
coverage, or if the plan is established pursuant to collective
bargaining.
(d) An employee and employer may agree to other forms of therapy
pursuant to Section 3209.7.
(e) An employee receiving treatment from
enrolled in a health care organization shall have the right to
no less than one change of physician on request, and shall be given a
choice of physicians affiliated with the health care organization.
The health care organization shall provide the employee a choice of
participating physicians within five days of receiving a request. In
addition, the employee shall have the right to a second opinion from
a participating physician on a matter pertaining to diagnosis or
treatment from a participating physician.
(f) Nothing in this section or Section 4600.5 shall be construed
to prohibit a self-insured employer, a group of self-insured
employers, or insurer from engaging in any activities permitted by
Section 4600.
(g) Notwithstanding subdivision (c), in the event that the
employer, group of employers, or the employer's workers' compensation
insurer no longer contracts with the health care organization that
has been treating an injured employee, the employee may continue
treatment provided or arranged by the health care organization. If
the employee does not choose to continue treatment by the health care
organization, the selection of a physician to provide
further medical treatment shall be in accordance with subdivision (c)
of Section 4600, except that the employee may, at any time 90 days
or more from the date the injury is reported, designate his or her
personal physician to provide further medical treatment in accordance
with subdivision (d) of Section 4600 in all respects other than the
condition that the employee notified the employer of prior to the
date of injury. the employer may control the employee'
s treatment for 30 days from the date the injury was reported. After
that period, the employee may be treated by a physician of his or her
own choice or at a f acility of his or her own choice
within a reasonable geographic area.
SEC. 2. Section 4600.5 of the Labor Code is amended to read:
4600.5. (a) Any health care service plan licensed pursuant to the
Knox-Keene Health Care Service Plan Act, a disability insurer
licensed by the Department of Insurance, or any entity, including,
but not limited to, workers' compensation insurers and third-party
administrators authorized by the administrative director under
subdivision (e), may make written application to the administrative
director to become certified as a health care organization to provide
health care to injured employees for injuries and diseases
compensable under this article.
(b) A certificate is valid for the period that the director may
prescribe unless sooner revoked or suspended.
(c) If the health care organization is a health care service plan
licensed pursuant to the Knox-Keene Health Care Service Plan Act, and
has provided the Managed Care Unit of the Division of Workers'
Compensation with the necessary documentation to comply with this
subdivision, that organization shall be deemed to be a health care
organization able to provide health care pursuant to Section 4600.3,
without further application duplicating the documentation already
filed with the Department of Managed Health Care. These plans shall
be required to remain in good standing with the Department of Managed
Health Care, and shall meet the following additional requirements:
(1) Proposes to provide all medical and health care services that
may be required by this article.
(2) Provides a program involving cooperative efforts by the
employees, the employer, and the health plan to promote workplace
health and safety, consultative and other services, and early return
to work for injured employees.
(3) Proposes a timely and accurate method to meet the requirements
set forth by the administrative director for all carriers of workers'
compensation coverage to report necessary information.
(4) Agrees to provide the administrative director with
information, reports, and records prepared and submitted to the
Department of Managed Health Care in compliance with the Knox-Keene
Health Care Service Plan Act, relating to financial solvency,
provider accessibility, peer review, utilization review, and quality
assurance, upon request, if the administrative director determines
the information is necessary to verify that the plan is providing
medical treatment to injured employees in compliance with the
requirements of this code.
Disclosure of peer review proceedings and records to the
administrative director shall not alter the status of the proceedings
or records as privileged and confidential communications pursuant to
Sections 1370 and 1370.1 of the Health and Safety Code.
(5) Demonstrates the capability to provide occupational medicine
and related disciplines.
(6) Complies with any other requirement the administrative
director determines is necessary to provide medical services to
injured employees consistent with the intent of this article,
including, but not limited to, a written patient grievance policy.
(d) If the health care organization is a disability insurer
licensed by the Department of Insurance, and is in compliance with
subdivision (d) of Sections 10133 and 10133.5 of the Insurance Code,
the administrative director shall certify the organization to provide
health care pursuant to Section 4600.3 if the director finds that
the plan is in good standing with the Department of Insurance and
meets the following additional requirements:
(1) Proposes to provide all medical and health care services that
may be required by this article.
(2) Provides a program involving cooperative efforts by the
employees, the employer, and the health plan to promote workplace
health and safety, consultative and other services, and early return
to work for injured employees.
(3) Proposes a timely and accurate method to meet the requirements
set forth by the administrative director for all carriers of workers'
compensation coverage to report necessary information.
(4) Agrees to provide the administrative director with
information, reports, and records prepared and submitted to the
Department of Insurance in compliance with the Insurance Code
relating to financial solvency, provider accessibility, peer review,
utilization review, and quality assurance, upon request, if the
administrative director determines the information is necessary to
verify that the plan is providing medical treatment to injured
employees consistent with the intent of this article.
Disclosure of peer review proceedings and records to the
administrative director shall not alter the status of the proceedings
or records as privileged and confidential communications pursuant to
subdivision (d) of Section 10133 of the Insurance Code.
(5) Demonstrates the capability to provide occupational medicine
and related disciplines.
(6) Complies with any other requirement the administrative
director determines is necessary to provide medical services to
injured employees consistent with the intent of this article,
including, but not limited to, a written patient grievance policy.
(e) If the health care organization is a workers' compensation
insurer, third-party administrator, or any other entity that the
administrative director determines meets the requirements of Section
4600.6, the administrative director shall certify the organization to
provide health care pursuant to Section 4600.3 if the director finds
that it meets the following additional requirements:
(1) Proposes to provide all medical and health care services that
may be required by this article.
(2) Provides a program involving cooperative efforts by the
employees, the employer, and the health plan to promote workplace
health and safety, consultative and other services, and early return
to work for injured employees.
(3) Proposes a timely and accurate method to meet the requirements
set forth by the administrative director for all carriers of workers'
compensation coverage to report necessary information.
(4) Agrees to provide the administrative director with
information, reports, and records relating to provider accessibility,
peer review, utilization review, quality assurance, advertising,
disclosure, medical and financial audits, and grievance systems, upon
request, if the administrative director determines the information
is necessary to verify that the plan is providing medical treatment
to injured employees consistent with the intent of this article.
Disclosure of peer review proceedings and records to the
administrative director shall not alter the status of the proceedings
or records as privileged and confidential communications pursuant to
subdivision (d) of Section 10133 of the Insurance Code.
(5) Demonstrates the capability to provide occupational medicine
and related disciplines.
(6) Complies with any other requirement the administrative
director determines is necessary to provide medical services to
injured employees consistent with the intent of this article,
including, but not limited to, a written patient grievance policy.
(7) Complies with the following requirements:
(A) An organization certified by the administrative director under
this subdivision shall not provide or undertake to arrange for the
provision of health care to employees, or to pay for or to reimburse
any part of the cost of that health care in return for a prepaid or
periodic charge paid by or on behalf of those employees.
(B) Every organization certified under this subdivision shall
operate on a fee-for-service basis. As used in this section, fee for
service refers to the situation where the amount of reimbursement
paid by the employer to the organization or providers of health care
is determined by the amount and type of health care rendered by the
organization or provider of health care.
(C) An organization certified under this subdivision is prohibited
from assuming risk.
(f) (1) A workers' compensation health care provider organization
authorized by the Department of Corporations on December 31, 1997,
shall be eligible for certification as a health care organization
under subdivision (e).
(2) An entity that had, on December 31, 1997, submitted an
application with the Commissioner of Corporations under Part 3.2
(commencing with Section 5150) shall be considered an applicant for
certification under subdivision (e) and shall be entitled to priority
in consideration of its application. The Commissioner of
Corporations shall provide complete files for all pending
applications to the administrative director on or before January 31,
1998.
(g) The provisions of this section shall not affect the
confidentiality or admission in evidence of a claimant's medical
treatment records.
(h) Charges for services arranged for or provided by health care
service plans certified by this section and that are paid on a
per-enrollee-periodic-charge basis shall not be subject to the
schedules adopted by the administrative director pursuant to Section
5307.1.
(i) Nothing in this section shall be construed to expand or
constrict any requirements imposed by law on a health care service
plan or insurer when operating as other than a health care
organization pursuant to this section.
(j) In consultation with interested parties, including the
Department of Corporations and the Department of Insurance, the
administrative director shall adopt rules necessary to carry out this
section.
(k) The administrative director shall refuse to certify or may
revoke or suspend the certification of any health care organization
under this section if the director finds that:
(1) The plan for providing medical treatment fails to meet the
requirements of this section.
(2) A health care service plan licensed by the Department of
Managed Health Care, a workers' compensation health care provider
organization authorized by the Department of Corporations, or a
carrier licensed by the Department of Insurance is not in good
standing with its licensing agency.
(3) Services under the plan are not being provided in accordance
with the terms of a certified plan.
(l) (1) When an injured employee requests chiropractic treatment
for work-related injuries, the health care organization shall provide
the injured worker with access to the services of a chiropractor
pursuant to guidelines for chiropractic care established by paragraph
(2). Within five working days of the employee's request to see a
chiropractor, the health care organization and any person or entity
who directs the kind or manner of health care services for the plan
shall refer an injured employee to an affiliated chiropractor for
work-related injuries that are within the guidelines for chiropractic
care established by paragraph (2). Chiropractic care rendered in
accordance with guidelines for chiropractic care established pursuant
to paragraph (2) shall be provided by duly licensed chiropractors
affiliated with the plan.
(2) The health care organization shall establish guidelines for
chiropractic care in consultation with affiliated chiropractors who
are participants in the health care organization's utilization review
process for chiropractic care, which may include qualified medical
evaluators knowledgeable in the treatment of chiropractic conditions.
The guidelines for chiropractic care shall, at a minimum, explicitly
require the referral of any injured employee who so requests to an
affiliated chiropractor for the evaluation or treatment, or both, of
neuromusculoskeletal conditions.
(3) Whenever a dispute concerning the appropriateness or necessity
of chiropractic care for work-related injuries arises, the dispute
shall be resolved by the health care organization's utilization
review process for chiropractic care in accordance with the health
care organization's guidelines for chiropractic care established by
paragraph (2).
Chiropractic utilization review for work-related injuries shall be
conducted in accordance with the health care organization's approved
quality assurance standards and utilization review process for
chiropractic care. Chiropractors affiliated with the plan shall have
access to the health care organization's provider appeals process
and, in the case of chiropractic care for work-related injuries, the
review shall include review by a chiropractor affiliated with the
health care organization, as determined by the health care
organization.
(4) The health care organization shall inform employees of the
procedures for processing and resolving grievances, including those
related to chiropractic care, including the location and telephone
number where grievances may be submitted.
(5) All guidelines for chiropractic care and utilization review
shall be consistent with the standards of this code that require care
to cure or relieve the effects of the industrial injury.
(m) Individually identifiable medical information on patients
submitted to the division shall not be subject to the California
Public Records Act (Chapter 3.5 (commencing with Section 6250) of
Division 7 of Title 1 of the Government Code).
(n) (1) When an injured employee requests acupuncture treatment
for work-related injuries, the health care organization shall provide
the injured worker with access to the services of an acupuncturist
pursuant to guidelines for acupuncture care established by paragraph
(2). Within five working days of the employee's request to see an
acupuncturist, the health care organization and any person or entity
that directs the kind or manner of health care services for the plan
shall refer an injured employee to an affiliated acupuncturist for
work-related injuries that are within the guidelines for acupuncture
care established by paragraph (2). Acupuncture care rendered in
accordance with guidelines for acupuncture care established pursuant
to paragraph (2) shall be provided by duly licensed acupuncturists
affiliated with the plan.
(2) The health care organization shall establish guidelines for
acupuncture care in consultation with affiliated acupuncturists who
are participants in the health care organization's utilization review
process for acupuncture care, which may include qualified medical
evaluators. The guidelines for acupuncture care shall, at a minimum,
explicitly require the referral of any injured employee who so
requests to an affiliated acupuncturist for the evaluation or
treatment, or both, of neuromusculoskeletal conditions.
(3) Whenever a dispute concerning the appropriateness or necessity
of acupuncture care for work-related injuries arises, the dispute
shall be resolved by the health care organization's utilization
review process for acupuncture care in accordance with the health
care organization's guidelines for acupuncture care established by
paragraph (2).
Acupuncture utilization review for work-related injuries shall be
conducted in accordance with the health care organization's approved
quality assurance standards and utilization review process for
acupuncture care. Acupuncturists affiliated with the plan shall have
access to the health care organization's provider appeals process
and, in the case of acupuncture care for work-related injuries, the
review shall include review by an acupuncturist affiliated with the
health care organization, as determined by the health care
organization.
(4) The health care organization shall inform employees of the
procedures for processing and resolving grievances, including those
related to acupuncture care, including the location and telephone
number where grievances may be submitted.
(5) All guidelines for acupuncture care and utilization review
shall be consistent with the standards of this code that require care
to cure or relieve the effects of the industrial injury.
SEC. 3. Section 4600.7 of the Labor Code is amended to read:
4600.7. (a) The Workers' Compensation Managed Care Fund is hereby
created in the State Treasury for the administration of Sections
4600.3 and 4600.5 by the Division of Workers' Compensation. The
administrative director shall establish a schedule of fees and
revenues to be charged to certified health care organizations and
applicants for certification to repay amounts received as a loan from
the General Fund. All fees and revenues shall be deposited in the
Workers' Compensation Managed Care Fund and shall be used when
appropriated by the Legislature solely for the purpose of carrying
out the responsibilities of the Division of Workers' Compensation
under Section 4600.3 or 4600.5.
(b) On and after July 1, 1998, no funds received as a loan from
the General Fund shall be used to support the administration of
Sections 4600.3 and 4600.5. The loan amount shall be repaid to the
General Fund by assessing a surcharge on the enrollment fee for each
of the next five fiscal years. In the event the surcharge does not
produce sufficient revenue over this period, the surcharge shall be
adjusted to fully repay the loan over the following three fiscal
years, with the final assessment calculated by dividing the balance
of the loan by the enrollees at the end of the final fiscal year.
