2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1305 - Workers' Compensation Health Care Networks › Subchapter J. Employee Information and Responsibilities › Section 1305.451. Employee Information; Responsibilities of Employee

Sec. 1305.451.  EMPLOYEE INFORMATION; RESPONSIBILITIES OF EMPLOYEE.  (a)  An insurance carrier that establishes or contracts with a network shall provide to employers, and the employer shall provide to its employees, an accurate written description of the terms and conditions for obtaining health care within the network's service area.
(b)  The written description required under Subsection (a) must be in English, Spanish, and any additional language common to an employer's employees, must be in plain language and in a readable and understandable format, and must include, in a clear, complete, and accurate format:
(1)  a statement that the entity providing health care to employees is a 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 statement that in the event of an injury, the employee must select a treating doctor:
(A)  from a list of all the network's treating doctors who have contracts with the network in that service area; or
(B)  as described by Section 1305.105;
(4)  a statement that, except for emergency services, the employee shall obtain all health care and specialist referrals through the employee's treating doctor;
(5)  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, except as provided by Subdivision (6);
(6)  a statement that if the employee obtains health care from non-network providers without network approval, except as provided by Section 1305.006, the insurance carrier may not be liable, and the employee may be liable, for payment for that health care;
(7)  information about how to obtain emergency care services, including emergency care outside the service area, and after-hours care;
(8)  a list of the health care services for which the insurance carrier or network requires preauthorization or concurrent review;
(9)  an explanation regarding continuity of treatment in the event of the termination from the network of a treating doctor;
(10)  a description of the network's complaint system, including a statement that the network is prohibited from retaliating against:
(A)  an employee if the employee files a complaint against the network or appeals a decision of the network; or
(B)  a provider if the provider, on behalf of an employee, reasonably files a complaint against the network or appeals a decision of the network;
(11)  a summary of the insurance carrier's or network's procedures relating to adverse determinations and the availability of the independent review process;
(12)  a list of network providers updated at least quarterly, including:
(A)  the names and addresses of the providers;
(B)  a statement of limitations of accessibility and referrals to specialists; and
(C)  a disclosure of which providers are accepting new patients; and
(13)  a description of the network's service area.
(c)  The network and the network's representatives and agents may not cause or knowingly permit the use or distribution to employees of information that is untrue or misleading.
(d)  A network that contracts with an insurance carrier shall provide all the information necessary to allow the carrier to comply with this section.
(e)  An issue regarding whether an employer properly provided an employee with the information required by this section may be resolved using the process for adjudication of disputes under Chapter 410, Labor Code, as used by the department's division of workers' compensation.
Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.
Amended by:
Acts 2011, 82nd Leg., R.S., Ch. 1066 (S.B. 809), Sec. 5, eff. September 1, 2011.