Bunch’s Texas Workers’ Compensation Health Care Network (HCN)

Bunch’s Texas Workers’ Compensation Health Care Network (HCN) Employer Presentation Created 3-07

Bunch’s Texas HCN - Background • June 1, 2005 - Texas House Bill 7 signed into law allowing the implementation of Health Care Networks (HCNs) on or after January 1, 2006. • December 2005 - Final regulations for the HCNs approved by the Texas Department of Insurance (TDI). • January 2006 - TDI begins reviewing submitted network filings.

Bunch’s Texas HCN – Health Care Network • What is a Health Care Network (HCN)? • A HCN is a network of providers that has been certified by the Texas Department of Insurance (TDI) to provide workers’ compensation health care to injured workers. • TDI certification ensures all specific requirements, including access and health care delivery standards, have been met. • Only those Geographic Service Areas (GSAs) that meet all health care access requirements will be approved. • Once certified, the network will continue to be monitored by TDI for quality and outcome measurements.

Key Points of HCN Regulations • An injured worker who lives* within an approved GSA must seek treatment within the HCN. • The employer may direct the initial non-emergency care to the HCN provider of choice. • Health care for the work-related injury or illness is to be delivered within the HCN for the life of the claim. • The employer has the ability to transfer care for existing WC injuries into the HCN. * Denotes the employee’s principal residence that is not a PO Box, a temporary residence required by employment or and address used for receiving help with daily activities

Key Points of HCN Regulations (continued) • Providers who leave the network may be allowed to continue to treat in order to maintain continuity of care. • The network specifies who can be considered a treating provider for the purposes of directing an injured workers treatment plan. • The rules have given an allowance for an injured worker to use their HMO treating provider (PTP) for the work-related injury if they designate their PTP prior to the injury.

Major Requirements for a TX HCN • TDI network access criteria • Specific provider contract requirements • Provider credentialing standards • Complaint and grievance process • Third party contracting requirements • Utilization review and case management requirements • Employee notification process • Treatment and return-to-work guidelines • Quality improvement plan

Network Access Requirements for GSAs • Adequate treating doctors, hospitals and specialists available 24/7 • In-patient and emergency care services within contracted general acute, specialty and psychiatric hospitals • Treating doctors or general acute hospitals accessible within 30 miles in non-rural, 60 miles in rural areas • Specialists accessible within 75 miles • Adequate number of doctors able to provide MMI / IR • A contracted general acute hospital within each non-rural county

Bunch’s Texas HCN – Case Management / UR • HCN Case Management and Utilization Review Requirements • Approved TX UR Agent • Medical Director must be licensed in Texas and be board certified in occupational medicine • Claim handlers may not perform case management functions • Case managers: • Certified by a national accrediting agency • Provide triage to assess the injury • Work with the treating provider, claim handler and employer to implement and coordinate a treatment plan • Evaluate options and services needed to provide appropriate medical care and facilitate timely return-to-work • Ensure continuity of care for injured workers

Bunch’s Texas HCN – Enrollment Employee Notification • Distribute the Employee Enrollment Package to all activeTexas employees at the following times: • Prior to implementation of the HCN • Within 3 days of a new employee being hired in Texas • When an employee is injured • Whenever a material change in the HCN occurs • Your claim handler will identify employees with existing injuries and evaluate them for potential transfer into the HCN.

Bunch’s Texas HCN – Enrollment Guide • The Employee Enrollment Guide consists of the following: • Employee Notification Letter as approved by TDI for HCN filing • Attachment A – Selecting a Provider through ProviderNet • Attachment B – Aetna TX HCN – Certified Counties • Attachment C – Treatment Guidelines • Attachment D – Description of Complaint System • Attachment E – Summary of Independent Review Process • Attachment F –Employee Acknowledgement Form

Bunch’s Texas HCN - Distribution • Any of the following methods may be used to distribute the notice and acknowledgment form to your employees: • Distribute the notice to employees at a scheduled staff or safety meeting and collect signed acknowledgment forms. Have a witness available if an employee refuses to sign the form. • Send a hard copy of the notice and acknowledgment form to all employees with a self-addressed return envelope for the acknowledgement form. • E-mail the notice to all employees and attach the acknowledgment form. Ask employees to complete and return the acknowledgment form. • Distribute the notice to employees electronically and obtain an electronic signature for your records. • Distribution of the information to employees must be documented (who, what, where and when).

Bunch’s Texas HCN – Next Steps • Work with your account manager to ensure you are following the correct employee notification process • Set a date for implementation of the HCN. Allow sufficient time for enrollment and collection of employee acknowledgment forms. • Start directing care for any new injuries that occur on or after the implementation date • Distribute the Employee Notification Package again to all employees who report a new work-related injury or illness after the implementation date

Bunch’s Texas Workers’ Compensation Health Care Network (HCN)