§ 10175. Definitions.

As used in this subchapter:

(a) “Employer” means any person defined as an employer in Section 3300 of the Labor Code who has secured the payment of workers' compensation benefits as required by Section 3700 of the Labor Code.

(b) “Exclusive provider of care option” means an option chosen by an employee under Section 10180 under which medical, surgical, and hospital treatment for both occupational and non occupational injuries and illness are provided to the employee through one health care service plan.

(c) “Health care service plan” means any of the following which offer a managed care product:

(1) A health care service plan licensed under Section 1353 of the Health and Safety Code (Knox-Keene Health Care Service Plan Act);

(2) A disability insurer authorized to transact health insurance or disability income insurance pursuant to Part 2 of Division 2 of the Insurance Code.

(3) An insurer authorized to transact workers' compensation insurance in California, including the State Compensation Insurance Fund.

(4) The state or an employer who has secured a certificate of consent to self-insure from the Director of Industrial Relations pursuant to Labor Code Section 3700.

(5) Multi-employer collectively bargained employee welfare benefit plans or an employee welfare benefit plan sponsored by a recognized exclusive bargaining agent for State employees.

(d) “Managed care product” means a system of medical care which provides for all of the following:

(1) All medical and health care services required under Section 4600 of the Labor Code in a manner that is timely, effective, and accessible to the employee. This shall include making available to an employee, within 5 days of a request, the services of any type of physician, as defined in Section 3209.3 of the Labor Code, including a chiropractor, following an initial visit with the employee's primary care physician, when treatment for an occupational injury or illness falls within the scope of practice of the requested type of physician.

(2) Appropriate case management, including direction of injured employees to appropriate medical service providers within a network for all non emergency services.

(3) Appropriate financial incentives to reduce service costs and utilization without sacrificing the quality of service, and mechanisms to identify and correct quality deficiencies.

(4) Adequate methods of quality assurance, peer review and service utilization review to prevent inappropriate or excessive treatment, and exclusion from participation those providers who violate treatment standards.

(5) Expertise in providing medical reports necessary for the prompt, proper administration of compensation, including those required under Sections 9785 and 10978.

(6) A procedure for resolving disputes concerning the provision of health care services under the plan, which shall be equivalent to that specified in Section 1368 of the Health and Safety Code.

(7) A program involving cooperative efforts by the employees, the employer, physicians, and other participants to promote employee wellness, workplace health and safety, and early return to work.

(8) Adequate mechanisms to assure coordinated case management goals and incentives among all providers of workers' compensation for employees with occupational injuries and diseases.

(e) “Principal place of business” means the location at which the majority of the employer's employees are employed.

(f) “Small employer” means an employer who on at least 50 percent of its working days during the calendar quarter preceding submission of the proposal under which the employer participates in the pilot project employed not more than fifty (50) employees.

(g) “Traditional health benefit plan” means a plan of medical coverage for non occupational injuries and illness provided by the employer, through a contract between the employer and a health care provider, or through a purchasing cooperative specifically authorized by state law.

(h) “Traditional workers' compensation provider” means a health care provider chosen pursuant to Labor Code Section 4600 or 4601.

HISTORY

1. New subchapter 1.7 and section filed 8-31-93; operative 8-31-93. Submitted to OAL for printing only pursuant to Government Code section 11351 (Register 93, No. 36).

Note

Note: Authority cited: Sections 133, 4612, and 5307.3, Labor Code. Reference: Section 4612, Labor Code.