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Texas Health Care Network – Agency Presentation. 2 What’s New Texas House Bill 7 (HB-7) Health Care Networks Coventry Workers’ Comp Network Out of Network.

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Presentation on theme: "Texas Health Care Network – Agency Presentation. 2 What’s New Texas House Bill 7 (HB-7) Health Care Networks Coventry Workers’ Comp Network Out of Network."— Presentation transcript:

1 Texas Health Care Network – Agency Presentation

2 2 What’s New Texas House Bill 7 (HB-7) Health Care Networks Coventry Workers’ Comp Network Out of Network Care Health Care Network Policy Endorsement Agent Role and Responsibility Employer and Employee Roles and Responsibilities Agent and Employer Tool Box

3 Texas Health Care Network – Agency Presentation 3 HB-7 Abolishes TWCC. Creates the Division of Workers’ Compensation (DWC) administered as a division of the Texas Department of Insurance (TDI). TDI approves and regulates the use of medical provider networks. Requires networks to select medical treatment guidelines, which network physicians must follow.

4 Texas Health Care Network – Agency Presentation 4 Health Care Networks Allows insurance carriers to create or contract with a network. Allows voluntary participation in a certified network at the employer level. Limits choice of physician to doctors selected by the network. Employees receive care for workplace injuries through the network IF they live in the network’s service area.

5 Texas Health Care Network – Agency Presentation 5 Why participate in a Health Care Network? Employee selects treating doctor at time of injury. Employer and carrier have more control over direction of care and medical treatment. Referral to appropriate specialty care is channeled within network. Network providers and emergency care must be available and accessible 24 hours a day, seven days a week. Focus on treatment and return-to-work outcomes. Improved quality of care.

6 Texas Health Care Network – Agency Presentation 6 Coventry Workers’ Comp Network CNA has contracted with Coventry to utilize the Coventry Workers’ Comp Network. The Coventry Workers’ Comp Network meets all state access and availability requirements. Primary care will be available within 30 miles in non rural areas, and 60 miles in rural areas. Specialty and hospital care will be available within 75 miles. The Coventry Workers’ Comp Network includes a continuous and comprehensive Quality Improvement program that is in accordance with state specific requirements.

7 Texas Health Care Network – Agency Presentation 7 Coventry Workers’ Comp Network – cont’d The Coventry Workers’ Comp Network includes a complaint process accessible to all injured workers. The Coventry Workers’ Comp Network provides a toll free 800 number to assist injured workers in finding a network physician. Network service area currently covers the greater Texas metropolitan areas, with anticipated extended coverage to include 97% of the workforce population.

8 Texas Health Care Network – Agency Presentation 8 Out of Network Care Carriers are responsible for out of network care involving: Emergency care. Care outside the service area. Care that has been referred and approved by the carrier. Care where the employee has not received appropriate notice of network requirements. The Approved Doctor’s List (ADL) remains in existence at least until September 1, 2007 for non-network care.

9 Texas Health Care Network – Agency Presentation 9 Health Care Network Policy Endorsement Employers who elect to provide workers’ compensation health care services through a certified network will need to have their policy endorsed. The underwriter will provide an application, which the insured will need to complete and sign, agreeing to follow the requirements of the HCN. The endorsement shows they have elected to participate and that their premium may have been reduced. Any applied premium reduction will be shown on the declarations page of the policy.

10 Texas Health Care Network – Agency Presentation 10 Role and Responsibility of Agent Explain the benefits of the Certified Network to your eligible customers. Explain the responsibilities of your eligible customers. Provide them with the CNA Web site so they can review detailed information about the program. If the employer elects to participate, notify your CNA underwriter. Assist the employer with any questions on how to implement the program. Contact your CNA underwriter/Client Service Director if you have any questions.

11 Texas Health Care Network – Agency Presentation 11 Role and Responsibility of Employer Prior to implementation, the employer must provide each employee with a letter and handbook entitled Employee Notification of Network Requirements. Each employee must sign an acknowledgement form, which states that the information was received. Employers should document to whom the notice was delivered, the method of delivery, the location of delivery and the date of delivery. An employee who does not sign the acknowledgement form still must comply with the network requirements. The employee handbook includes information about the employee’s right to receive care from their HMO primary care doctor if they receive group health benefits from an HMO. The HMO doctor must agree to abide by the network’s terms and conditions.

12 Texas Health Care Network – Agency Presentation 12 Role and Responsibility of Employer – cont’d: Post notice of network requirements at each place of employment. Provide the employee acknowledgement letter and handbook to new employees no later than the third day after the date of hire. Provide the employee acknowledgement letter and handbook to an injured employee at the time the employer receives actual or constructive notice of an injury. If the employee refuses to use the network, any out of network expenses may be the liability of the employee.

13 Texas Health Care Network – Agency Presentation 13 Role and Responsibility of the Employee Read and acknowledge the Employee Notification of Network Requirements. If employees would like to use their HMO primary treating physician as their network treating doctor, they must fill in that doctor’s name at the time of notification. If they have an emergency, they should be instructed to get immediate medical care. When an injury occurs, they should choose a treating doctor from the network list. For existing claims, employees should select a treating doctor from the network list within 14 days or a treating doctor will be selected for them.

14 Texas Health Care Network – Agency Presentation 14 Role and Responsibility of the Employee – cont’d If employees choose to change their treating doctor, they must choose a doctor from the network list. Change to a third doctor requires permission from CNA. Employees may have to pay for medical expenses if they do not use a network doctor.

15 Texas Health Care Network – Agency Presentation 15 Agent and Employer Tool Box Visit the CLAIM page within to access:http://www.cna.com −Employee Communication Materials. −Frequently Asked Questions. −Agent and Employer Presentations. Provider Look up - Client ID: TXHCN.http://www.geoaccess.com/cvty/Client.asp Single point of contact for provider search, provider list or provider nominations through Case Management Provider Coordinator: Alyson Arguijo for network questions. Your CNA Client Service Director, Claim Consultant, or Case Manager.

16 One or more of the CNA companies provide the products and/or services described. The information is intended to present a general overview for illustrative purposes only. It is not intended to substitute for the guidance of retained legal or other professional advisors or to constitute a binding contract. Please remember that only the relevant insurance policy or claim service agreement can provide the actual terms, coverages, amounts, conditions and exclusions. Use of the term "partnership" and/or "partner" should not be construed to represent a legally binding partnership. All products and services may not be available in all states and may be subject to change without notice. CNA is a service mark registered with the United States Patent and Trademark Office. Copyright © 2008 CNA. All rights reserved.


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