Katrina Daniel Associate Commissioner Life, Health and Licensing Program Texas Department of Insurance

1. Texas Department of Insurance Status of Workers’ Compensation Health Care Networks in Texas Katrina Daniel Associate Commissioner Life, Health and Licensing Program Texas Department of Insurance TSIA Conference June 8, 2009 Austin, TX

2. Texas Department of Insurance What are Workers Compensation Health Care Networks? Organizations that are: • Formed to provide health care services to injured employees, • Certified in accordance with Insurance Code Chapter 1305 and related rules, and • Established by, or contracted with an insurance carrier (includes a certified self-insured employer).

3. Texas Department of Insurance House Bill 7 – 79th Legislature(Insurance Code Chapter 1305) • Authorizes the establishment of workers’ compensation health care networks • Provides standards for the certification, administration, evaluation, and enforcement of health care service delivery by networks

4. Texas Department of Insurance Networks: Who and how many? • Formed by carriers, managed care entities, TPAs, self-insured employers and self-insured governmental entities • 33 Certified Networks • Complete list of certified networks provided at end of presentation • Service area and contact information for each network is available atwww.tdi.state.tx.us/wc/wcnet/wcnetworks.html • 59 Approved Service Area Expansions • 0 Pending Certifications • 5 Pending Service Area Expansions

5. Texas Department of Insurance Certified WC Networks per County

6. Aetna Workers' Comp Access (AWCA) Argus Provider Network Bunch & Associates, Inc. Texas Health Care Network Bunch Coventry TX HCN dba Bunch & Associates Bunch HCN-First Health Corvel Healthcare Corporation / Corcare Coventry Health Care Workers Compensation Inc. First Health / AIGCS Texas Health Care Network First Health/CSS HCN First Health Texas Health Care Network First Health / Travelers Health Care Network Forte Inc. / Compkey Plus Genex Services Inc. / Genex Care For Texas' Comp Access (AWCA) Genex Services Inc. / Genex Health Care Network Hartford Workers' Compensation Health Care Network- FH, The Houston Independent School District IMO Med-Select Network / Injury Management Organization, Inc. Interplan Health Group, Inc. / Zenith Health Care Network (ZHCN) International Rehabilitation Associates, Inc. / Intracorp-2008 Intracorp / Lockheed Martin Aero Employee Select Network 2008 Liberty Health Care Network  Majoris Health Systems Memorial Hermann Health Network Providers, Inc. / Worklink  National Choicecare,  NCC Choicenet North Texas Innovative Healthcare Network, Inc. Sedgwick Claims Management Service, Inc./ Southwest Medical Provider Network SHA, LLC / /Firstcare Network Specialty Risk Services Texas Workers' Compensation Health Care Network (First Health) Texas Star Network The lone Star Network Zurich Services Corporation Healthcare Network Zurich Services Corporation Healthcare Network / Corvel Zurich Services Corporation Healthcare Network (HCN)- First Health Texas Department of Insurance Texas Certified WC Networks

7. Texas Department of Insurance Network Size • Largest Service Area = 234 counties • Smallest Service Area = 1 county • Largest Provider Panel = 8,703 providers • Smallest Provider Panel = 47 providers

8. Certified Self-Insureds Assume the responsibilities of: • Carriers, • Employers, and • Networks (if own network is formed and certified).

9. Texas Department of Insurance Network Options • Carriers (includes insurance companies, certified self-insured employers, and certain self-insured governmental entities) can: • Contract with certified network, or • Form a network and apply for certification.

10. Texas Department of Insurance Application Requirements • Organizational description • Financial information and business plan • Contracts with 3rd parties and form of provider contract • Service area maps and descriptions • Provider panel – contracted and credentialed • Proof that care is accessible, available, comprehensive • Treatment and return to work guidelines (Refer to 28 TAC §10.22 for complete list of requirements)

11. Texas Department of Insurance Provider Contract Requirements • No transfer of risk • Fee schedule • Hold-harmless clause for injured employees • No retaliation for appealing on patient’s behalf • List of services requiring preauthorization • Agreement to use network treatment guidelines • Provider appeal process for terminations • Agreement to participate in certified network (Refer to 28 TAC §10.42 for complete list of requirements)

12. Texas Department of Insurance Employee Notice -Acknowledgment Form Requirements • Service area map and description • Must use network providers if living in service area • Except emergency & approved out-of-network referral • Employee living in service area may be liable for non-emergent, unapproved, out-of-network care • No charge for network care for compensable injury • Complaint process explained • Right to contest where employee lives • Provider directory updated quarterly • Acknowledgment form (Refer to 28 TAC§10.60 for complete list of requirements)

13. Texas Department of Insurance Employee Responsibilities An employee who lives in the service area must: • Comply with network requirements, • Select treating provider for each injury from list of network providers or HMO PCP, • Obtain care through network providers except for emergency and approved out-of-network care, and • Notify employer of any change of address.

14. Texas Department of Insurance Network Responsibilities • Maintain adequate, accessible network • Credential and contract with providers • Update provider directories • Meet access standards • Treating providers: 30 miles in urban areas and 60 miles in rural areas • Specialty care providers: 75 miles in all areas • Arrange for care within appropriate time but no later than 21 days after request • File amendments to application within time constraints

15. Texas Department of Insurance Employer Responsibilities • Provide notice of network requirements and get signed acknowledgment: • Either at inception of the network plan or within employee’s 3rd day of employment • Obtain and maintain acknowledgment form signed by employee • Provide notice of network requirements to the employee again at the time they are notified of an injury • Establish standardized process to notify employees of network requirements • Maintain current addresses of employees

16. Texas Department of Insurance Insurance Carrier Responsibility for Out-of-network Care • Emergency care • Care provided to an injured employee who does not live in the service area • Care provided out-of network pursuant to a network-approved referral from the injured employee’s treating doctor • Care provided to an injured employee before the employee received notice of network requirements and information about the appropriate network and service area

17. Texas Department of Insurance Certified Self-Insureds Assume the responsibilities of: • Carriers, • Employers, and • Networks (if own network is formed and certified).

18. Texas Department of Insurance Legislative Changes: 80th Legislature SB 458 • Amends Labor Code §401.011 • Requires coverage for prosthetic or orthotic devices including the fitting of, change or repair to, or training in the use of an appliance, brace, member or device

19. Texas Department of Insurance Legislative Changes: TX R 80th Legislature HB 472 • Amends Insurance Code Chapter 4151 • Requires a person who adjusts or settles claims for workers compensation benefits and a certified network that administers a workers compensation claim for an insurer to hold a certificate of authority as a Third Party Administrator.

20. Texas Department of Insurance Legislative Changes: TX R 80th Legislature HB 1005 • Adds Labor Code §408.0272 • Creates an exception to the 95-day claim filing requirement if the provider submits proof that the claim was • timely filed to the worker’s health insurer, HMO or another workers’ compensation carrier or • not timely filed due to a catastrophic event, as defined, and • correctly refiled within in 95 days of receiving notice of the erroneous filing.

21. Texas Department of Insurance Legislative Changes: 80th Legislature HB 1006 • Amends Insurance Code Chapter 1305 • Requires that doctors who perform reviews of health care services including utilization, retrospective and peer reviews be licensed in Texas

22. Texas Department of Insurance Legislative Changes: 80th Legislature SB 1253 • Amends Insurance Code §1305.251 • Requires networks to pay a fee as set by the Commissioner by rule for examination expenses

23. Texas Department of Insurance Resources • To obtain list of certified networks, service area maps, all-network combined map, etc. go to www.tdi.state.tx.us • Locate the star in the upper left corner and click on “Workers Compensation Networks” which is located to the right of the star • Scroll down to view information on certified networks and click on a network’s name for additional details

24. Texas Department of Insurance Questions? • Send an e-mail to wcnet@tdi.state.tx.us • Please include your contact information and phone number • Call TDI Health and Workers’ Compensation Network (HWCN) staff • 800-554-4926 (toll-free) • 512-322-4266 (in Austin)

25. Aetna Workers' Comp Access (AWCA) Argus Provider Network Bunch & Associates, Inc. Texas Health Care Network Bunch Coventry TX HCN dba Bunch & Associates Bunch HCN-First Health Corvel Healthcare Corporation / Corcare Coventry Health Care Workers Compensation Inc. First Health / AIGCS Texas Health Care Network First Health/CSS HCN First Health Texas Health Care Network First Health / Travelers Health Care Network Forte Inc. / Compkey Plus Genex Services Inc. / Genex Care For Texas' Comp Access (AWCA) Genex Services Inc. / Genex Health Care Network Hartford Workers' Compensation Health Care Network- FH, The Houston Independent School District IMO Med-Select Network / Injury Management Organization, Inc. Interplan Health Group, Inc. / Zenith Health Care Network (ZHCN) International Rehabilitation Associates, Inc. / Intracorp-2008 Intracorp / Lockheed Martin Aero Employee Select Network 2008 Liberty Health Care Network  Majoris Health Systems Memorial Hermann Health Network Providers, Inc. / Worklink  National Choicecare,  NCC Choicenet North Texas Innovative Healthcare Network, Inc. Sedgwick Claims Management Service, Inc./ Southwest Medical Provider Network SHA, LLC / /Firstcare Network Specialty Risk Services Texas Workers' Compensation Health Care Network (First Health) Texas Star Network The lone Star Network Zurich Services Corporation Healthcare Network Zurich Services Corporation Healthcare Network / Corvel Zurich Services Corporation Healthcare Network (HCN)- First Health Texas Department of Insurance Texas Certified WC Networks