Network participation comes with responsibilities for employers and their employees.
- Texas requires that at the time of network selection or within three days of new employee hire and at the time of injury, employers must provide employees with a notice of network requirements. The notice must be in English, Spanish or any other language common to employees. It must include a list of network providers, a notice that the employee must see a treating doctor that is in the network, and an explanation of the complaint process.
- In addition to delivering the notice, employers must obtain a signed acknowledgment form from employees at the time of notice and the time of injury. Employers must establish a standardized process for delivering the notice. Texas Mutual has a template employers can use to record delivery and employees' signatures. If an employee refuses to sign the acknowledgment, he or she will still be required to comply with the terms of the network if the employer fulfills his responsibility and maintains a record of delivery.
Employers that choose to distribute the notice of network requirements at an employee meeting may want to also show our employee presentation, which explains several key elements of the notice and employee responsibilities.
NOTE: To play the Windows Media file, you must have Windows Media Player installed on your computer. Download a free copy. A PowerPoint-only version of the employee presentation is available. We also have the presentation available in Spanish.
NOTE: If an employee has not received the notice at the time of injury, they may not be obligated to network requirements until notice is provided, and they may seek care from any provider who is licensed to practice in Texas. Texas Mutual will reimburse the provider for medical care delivered in accordance with Division of Workers' Compensation fee guidelines and will begin the process of transferring the claim to the network.
Employees who meet the following conditions must seek care within the network:
- the policyholder has purchased a policy with network coverage
- the policyholder has provided the employee with the required notice and obtained a signed acknowledgement form
- the employee lives within a network's service area
If the employee meets these conditions, he or she must select a treating doctor from among the doctors offered by the network in their service area. If the employee does not seek care within the network, he or she may be responsible for payment to non-network medical providers.
Employees are entitled to one change of treating doctor within the network. Any subsequent requests to change treating doctor must be approved by the network.
Employees may seek treatment from their HMO doctor, if the HMO doctor will accept the network's terms and conditions. This provision does not apply to preferred provider organization (PPO) plans or family doctors. Employees who select their HMO primary care physician as their treating doctor should inform Texas Mutual Insurance Company.
In addition to the ability to treat with their HMO doctor, employees may go outside the network:
- if they live outside the network's service area
- to receive emergency care
- to visit a specialist upon the referral of their network treating doctor