Report Title:

Workers' Compensation; Public Employees; Coordinated Care

Description:

Establishes a coordinated care system option to provide workers' compensation benefits for public employees.

HOUSE OF REPRESENTATIVES

H.B. NO.

2647

TWENTY-THIRD LEGISLATURE, 2006

 

STATE OF HAWAII

 


 

A BILL FOR AN ACT

 

relating to workers' compensation.

 

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF HAWAII:

SECTION 1. Chapter 386, Hawaii Revised Statutes, is amended by adding a new part to be appropriately designated and to read as follows:

"PART    . COORDINATED CARE ORGANIZATIONS FOR MEDICAL

AND REHABILITATIVE SERVICES PROVIDED TO

PUBLIC EMPLOYEES SUBJECT TO CHAPTER 89

§386-A Purpose. (a) A system of coordinated care to provide coverage for the medical and rehabilitative benefits of a policy required under this chapter shall have the following purposes:

(1) Minimize workplace injuries and promote workplace health and safety, through a cooperative effort among the employer, the employer's workers' compensation insurer, the employee, and the coordinated care organization under section 386-H;

(2) Provide efficient, cost effective, and timely treatment through a coordinated and comprehensive system of quality health care, including the use of case management;

(3) Provide a high level of quality of care;

(4) Provide an understandable, accessible, and user friendly system of care, including open and direct communication and cooperation among the employer, the employer's workers' compensation insurer, the employee, and the coordinated care organization;

(5) Provide a range of treatment, including but not limited to office, clinic, laboratory, hospital, rehabilitative, emergency, and other essential care;

(6) Make available a variety of specialties as may be necessary and several providers within each specialty to afford comprehensive care and a choice of provider to the employee;

(7) Provide a prompt and appropriate return to work program to assist an injured employee to return to work safely without unnecessary medical delay, and provide the employer and the employer's workers' compensation insurer with timely medical information, including work return status, recommended work restrictions, projected date of return to work, and degree of maximum medical improvement;

(8) Provide a vocational rehabilitation program under section 386-25; and

(9) Provide a program of internal dispute resolution processes such as mediation to reduce the adversarial nature of workers' compensation; provided that the administrative and appeals process under this chapter shall be available to the injured employee at all times.

(b) The provisions of subsection (a), except for subsection (a)(1), are guidelines to assist a coordinated care organization registered under section 386-D in forming a system of coordinated care and to assist the employer, the employer's workers' compensation insurer if the employer is not self-insured, or a collective bargaining unit in selecting a coordinated care organization.

(c) If a conflict arises in any particular case among the listed purposes in subsection (a), then subsection (a)(3) shall prevail.

§386-B Application and authorization. (a) This part shall not apply without the mutual authorization of the exclusive representative of a collective bargaining unit established under section 89-6 and the employer. For the purposes of this part, "employer" means only the State, any county or political subdivision of the State, and any other public entity within the State.

(b) If there is a mutual authorization under subsection (a), a negotiated agreement under section 386-3.5 may include the use of a registered coordinated care organization to provide coverage for medical and rehabilitative services required under this chapter.

§386-C Who may form. (a) The following groups may form a coordinated care organization for purposes of section 386-B:

(1) An employee organization, as defined in section 89-2;

(2) A mutual benefit society certified under chapter 432:1;

(3) A health maintenance organization certified under chapter 432D;

(4) An insurer offering a policy under chapter 431:10A; and

(5) An association, partnership, or professional corporation of physicians and other health care providers, including hospitals, rehabilitation services, and emergency care providers.

(b) For purposes of section 386-B, an organization listed in subsection (a) shall operate under this chapter through a workers compensation insurer providing benefits under chapter 386.

§386-D Registration. (a) A coordinated care organization qualified under section 386-C shall register with the department. The registration shall be submitted on forms specified by the department and shall include the following information:

(1) Name, address, and phone number of the organization;

(2) Identity of members of the organization, including but not limited to, health care providers, clinics, and hospitals or other medical facilities;

(3) Services provided by the organization; and

(4) Description of a plan of organization and operation to implement the purposes under section 386-A.

(b) Registration under subsection (a) shall be a prerequisite for providing coverage for medical and rehabilitative services for purposes of section 386-B. The department shall not accept any registration submitted by an organization that does not meet the requirements of section 386-C.

(c) A coordinated care organization shall file one or more plans or agreements as samples with its registration under subsection (a) for purposes of section 386-A(b). Plans or agreements shall not be subject to approval by the department.

(d) Violation of this section shall nullify any agreement or contract under section 386-B.

§386-E Registration fee. (a) The purpose of this section is to provide for a self-sustaining coordinated care organization system. Employers, insurers, health care providers, and other organizations may realize a cost savings from forming a coordinated care organization. Because these savings accrue to their benefit, these entities shall be assessed a filing fee under subsection (b) so that the State is not burdened with added expense.

(b) Each registration filed under section 386-D shall be accompanied by a registration fee of $10,000.

(c) There is established a coordinated care organization special fund to be administered by the department. Sums received by the department for registration under this section shall be deposited into the fund. The fund shall be used by the department to defray costs and expenses incurred by the department under this part. Unexpended moneys remaining in the special fund upon repeal of this section shall lapse into the general fund.

§386-F Solvency and fee schedules. (a) A registered coordinated care organization may have a negotiated amount paid by the employer, employer's workers' compensation insurer, or a collective bargaining unit, as applicable, for all services provided to all covered employees.

(b) If the negotiated amount under subsection (a) is a fixed sum for comprehensive care for work injuries, the coordinated care organization shall be subject to the solvency requirements, as follows:

(1) For a health insurer under chapter 431:10A, chapter 431:5 shall apply;

(2) For a mutual benefit society, chapter 432 shall apply;

(3) For a health maintenance organization, chapter 432D shall apply; and

(4) An employee organization under section 89-2 or an association under section 386-C(a)(5) shall post bond with the insurance commissioner in an amount that the insurance commissioner deems sufficient.

(c) A coordinated care organization shall not be subject to regulation under the insurance code if:

(1) The negotiated amount under subsection (a) is in the form of assessments, dues, or contributions; and

(2) The payment to health care providers for rendering health care and service for work injuries is based upon a fee for each service.

(d) Fee schedules shall be as provided under section 386-21(c).

§386-G Treatment and utilization protocols. (a) A registered coordinated care organization shall be exempt from the requirements under section 386-26; provided that the frequency and extent of treatment shall not be less than required by the nature of the injury and the process of recovery. Treatment and utilization protocols shall be subject to approval by the department, if the department finds that the protocols of a particular coordinated care organization warrant an approval procedure to ensure that a high level of quality of care is provided. The director shall have a health care provider advisory committee to advise the department on approval of protocols.

(b) If the employee believes that more treatment is necessary than that provided under subsection (a), the employee and the coordinated care organization shall utilize the procedures under section 386-A(a)(9) to ensure that a high level of quality of care is provided.

(c) An employer's workers' compensation insurer shall not deny approval of treatment if the treatment is within subsection (a).

§386-H Choice of coordinated care organization; choice of provider. (a) An employer may select two or more registered coordinated care organizations for purposes of this part. The employee shall have a choice of selecting one or need not select any.

(b) Prior to the employee's selection of a coordinated care organization under subsection (a), the employer shall provide the employee with information about each coordinated care organization that is being offered to the employee. The information shall include a list of names, addresses, and specialties of the individual health care providers who provide services for the coordinated care organization.

(c) A registered coordinated care organization shall provide to an employee in its program a choice of physicians and specialists. The employee may change a physician or a specialist, as provided in section 386-21(b), within a coordinated care organization.

(d) Nothing in this section shall limit receiving emergency medical treatment for a work injury from any health care provider or medical services provider. Emergency medical treatment shall be paid by the employer's workers' compensation insurer or the self-insured, as applicable.

(e) This section shall not be construed to affect section 386-21(b) with regard to changing a medical services provider.

§386-I Independent medical examination. (a) The employer, the employer's workers' compensation insurer if the employer is not self-insured, or the injured worker may request an independent medical examination for good cause. A case manager under section 386-J shall refer the injured worker to an appropriate health care provider for an independent medical examination outside of the coordinated care organization. The independent medical examiner shall examine the injured worker, review the records, and render a medical report.

(b) If the injured worker refuses to accept the health care provider designated by the case manager under subsection (a), the coordinated care organization and the injured worker shall agree upon another health care provider who is appropriately qualified to perform an independent medical examination.

(c) An independent medical examination under this section shall be performed within twenty-one days of the referral under subsection (a).

(d) The employer or the employer's workers' compensation insurer if the employer is not self-insured, as applicable, shall pay for the examination and report under subsection (a). The cost of the examination or report shall be subject to approval of the director if the cost is contested. The independent medical examination report shall be submitted to the coordinated care organization, the employer, the employer's workers' compensation insurer if the employer is not self-insured, and the employee.

§386-J Case management. A registered coordinated care organization shall assign a case manager to each injured employee to facilitate the accomplishment of the purposes under section 386-A. The case manager shall be a registered nurse who holds a national certification as a case manager or a registered nurse who is otherwise professionally qualified to provide case management services as determined by the registered coordinated care organization."

SECTION 2. (a) There is established a coordinated care organization review task force that shall be administratively attached to the department of labor and industrial relations.

The task force shall consist of the following ten members:

(1) Director of labor and industrial relations;

(2) Insurance commissioner; and

(3) Eight persons appointed by the director of labor and industrial relations, one to represent each of the following: public sector labor, management, coordinated care organizations, health care providers involved with a coordinated care organization, workers' compensation insurers, nurse case managers, vocational rehabilitation specialists, and the general public.

If a vacancy occurs, the vacancy shall be filled for the unexpired term in the same manner as the office was previously filled. The members shall serve without compensation but shall be reimbursed for all necessary expenses.

(b) The task force shall monitor and study the coordinated care organization system established by this Act to:

(1) Ensure that a sufficient level of quality care is maintained, while giving consideration to balancing the interests of employers and employees;

(2) Evaluate the effectiveness of each registered coordinated care organization in achieving the purposes set forth under section 386-A, Hawaii Revised Statutes;

(3) The accessibility of medical specialist care to injured employees, including considerations of island by island availability of medical specialists who are willing to treat injured employees under chapter 386, Hawaii Revised Statutes;

(4) Make recommendations, if any, to strengthen the coordinated care organization system; and

(5) Compare workers' compensation insurance premiums paid by employers before and after utilizing coordinated care organizations.

(c) The insurance commissioner, the department of labor and industrial relations, all other state agencies, and all registered coordinated care organizations shall cooperate with the task force in the study by providing information to the task force upon request. The information shall include the number of employees enrolled in the coordinated care organization, number of disenrolled employees, and the reasons for disenrollments.

(d) The task force shall submit a report of its findings and recommendations to the legislature and the governor no later than twenty days prior to the convening of the regular session of 2011.

SECTION 3. If any provision of this Act or the application thereof to any person or circumstance is held invalid, the invalidity does not affect other provisions or applications of the Act which can be given effect without the invalid provision or application, and to this end the provisions of this Act are severable.

SECTION 4. In codifying the new sections added by this Act, the revisor of statutes shall substitute the appropriate section numbers for the letters used in designating the new sections in this Act.

SECTION 5. This Act shall take effect upon its approval.

INTRODUCED BY:

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