|
Issue
|
Existing Law
|
SB899
|
| |
Specifies that measurements
of physical elements of disability
should follow the recommendation
of the Joint Committee of the California
Medical Association and Industrial
Accident Commission published in
1960. |
Requires procedures
for determining
diagnosis and treatment to be in
accordance with the American
College of Occupational and
Environmental Medicine (ACOEM)
guidelines and where ACOEM is not
applicable, with peer reviewed,
evidence-based, nationally
recognized standards of care.
Restricts the admissibility of
evidence of disability or
reasonableness of medical treatment
to reports that comply with the
procedures above. |
Medical Provider
Networks |
Allows an employer
to contract with a state certified
health care organization (HCO) for
provision of medical care. |
Allows employers
to contract with closed networks
of doctors the same way they do
now in group health. In exchange,
the employee would be allowed to
change doctors within the network.
The network must meet certain
requirements to ensure adequate
and appropriate care (sufficient
geographic coverage, an adequate
number of specialists, a
specified percentage of
physicians who are primarily
non-occupational, timelines for
seeing network doctors,
continuity of care, etc)
The worker could see up to three
different doctors within the network
and is then eligible for an in person
independent medical review (IMR)
The employer pays for IMR. If the
IMR sides with the injured worker,
the employee can receive his or
her medical treatment outside of
the network at the expense of the
employer. |
|
Predesignation
of Physician |
The employer has
medical control for the first thirty
days after an injury is reported.
If the employee pre-designated a
personal physician, the employee
has the right to be treated by that
physician from the date of the injury. |
Under the following
conditions, the worker would be
allowed to receive care from their
group HMO or PPO instead of from
the employer’s network:
• If the employer
provides group health insurance
and the worker pre-designates his
or her treating3 physician within
the group.
• Referrals to
specialists are approved by the
insurer and take place within the
HMO or PPO.
The total number
of workers who pre-designate does
not exceed 7 percent.
In cases where
the employee predesignates, he or
she would be bound by all of the
rules of group health insurance.
The Division of
Workers’ Compensation would study
predesignation to see whether it
is cost effective. The right to
predesignate would sunset in three
years.
|
|
Immediate
Medical Care |
Allows for up to
90 days to make a decision on a
claim and to begin providing the
necessary medical care. |
Rather than
allowing an employer 90 days to
begin treatment, employees would
receive immediate medical
treatment with a cap of $10,000. |
|
Standard of
Care |
Provides for
treatment that is reasonably
required to “cure and relieve”
from the effects of the injury. |
The current
standard of care, ‘cure and
relieve” is defined as treatment
in accordance with American
College of Occupational and
Environmental Medicine (the
treatment guidelines in last
year’s legislation). |
|
24 Hour Care
Pilots |
Provides for
carve-out programs, which permit
the same basic benefits to be
delivered when a union and an
employer establish an alternate
dispute resolution process
instead of the usual litigation
process. |
Expands carve-out
programs to allow a seamless
health and disability system,
without regard to the cause of
the sickness or disability,
provided they maintain the
statutory minimums for PD
benefits. The option for 24-hour
integrated coverage would be
included within the existing
carve-out programs. |
|
Repeal of the
Treating Physician Presumption |
The opinion of
the treating physician is
presumed to be correct if the
physician was predesignated. |
Repeals the
treating physician presumption
for pre-designated physicians. |
|
5814 Penalties |
When payment of
compensation has been
unreasonably delay or refused,
the entire species of benefits
is increased by 10%. TD, PD, and
medical treatment are all
considered species of benefits. |
When payment of
compensation has been
unreasonably delay or refused:
• The penalty
would be 25 percent of the late
payment. There would be a
$10,000 cap on a 5814 penalty.
Late payment to a medical
provider would not constitute a
5814 penalty unless significant
harm was caused to the worker as
a result of the late payment (he
or she didn’t receive a
necessary treatment, for
example).
• If an
insurer discovered that they had
failed to pay a claim on time or
at the right amount, they could
“self-correct” by sending it off
with an additional 10 percent
added. This would have to happen
before a 5814 was filed.
• There is a
penalty for pattern of practice
of up to $400,000.
• There would
be a two-year statute of
limitations on 5814 penalties. |
|
Causation |
Provides
compensation for any injury
arising out of and occurring in
the course of employment. The
injury may be specific or
cumulative and employment need
not be the sole cause of the
injury. |
No change. |
|
Permanent
Disability Apportionment |
When a
pre-existing disease is
aggravated by an industrial
injury, allows for compensation
due to the aggravation. An
employee with a previous
permanent disability is entitled
to compensation only for the
increase in disability resulting
from the industrial injury. |
Apportions
compensation to any non-work
cause: an existing injury,
health condition, etc. Requires
doctors’ reports to address the
issue of apportionment.
Caps multiple
awards so that an individual
cannot get more than 100 percent
disability for any single region
of the body. Specifies that in
no case shall an injured worker
receive cumulative awards that
exceed the benefit of a total
permanent disability award.
Requires an
employee to disclose all
relevant injuries and all
previous relevant compensated
injuries.
Creates a
conclusive presumption that
prior awards or stipulations
continue to exist. |
|
Temporary
Disability |
Caps TD at 240
weeks within a period of 5 years
from the date of injury. |
Caps TD at 104
weeks within 2 years from the
first payment by an employer.
Specifies that
workers with the following
conditions can receive TD longer
than 104 weeks.
• Acute and
Chronic Hepatitis A and C
• HIV
• Amputations
• Severe Burns
• High
Velocity Eye Injuries and
Chemical Burns to the Eyes
• Pulmonary
Fibrosis and Chronic Lung
Disease |
|
Insurance Rate
Report |
N/A |
Requires the
Division of Workers’
Compensation in consultation
with Department of Insurance to
contract for a report on the
impact that the cost savings
from this bill and last year’s
form bills have on rates.
Requires the study to address
the appropriateness of rate
regulation. |
|
User Funding |
Until 1/1/04, the
Division of Workers’
Compensation was funded 20% by
user funding and 80% from the
General Fund. Last year’s
legislation intended to provide
for 100% user funding, but that
never happened due to an error
with the language. |
Restores 100%
user funding of the Division of
Workers’ Compensation. |
|
Return to Work
Program |
Provides for a
return to work program for small
employers that was unfunded. |
Establishes and
funds (through user funding) a
return to work program that
provides up to $2500 to small
employers who need to make
workplace modifications in order
to return injured workers to
their jobs. |