HB1172

Report Title:

Workers' Compensation; Coordinated Care Organizations

Description:

Regulates coordinated care organizations in the treatment of workers' compensation injuries.

HOUSE OF REPRESENTATIVES	H.B. NO.	1172
TWENTY-THIRD LEGISLATURE, 2005
STATE OF HAWAII

A BILL FOR AN ACT

relating to coordinated care organizations.

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

§386-A Coordinated care organizations; filing; fee; guidelines. (a) Any group of health care providers establishing a coordinated care organization to provide medical care, services, and supplies to injured workers under this part shall register the coordinated care organization plan with the director. The registration shall set forth the information regarding compliance of the proposed plan with the requirements of subsection (b). Each registration filed under this section shall be accompanied by a registration fee of $10,000.

(b) A coordinated care organization plan qualifying under this part shall include:

(1) Established quality assurance and treatment standards, with treatment utilization guidelines based on customary practices for the utilization of appropriate diagnostic tests and medical treatments, to provide an injured worker with all the medical care, services, and supplies required by this chapter in a manner that is timely, effective, and convenient for the worker so long as reasonably needed as the nature of the injury requires;

(2) A list of the health care providers who will provide services under the coordinated care organization, together with evidence of compliance by the individual health care providers with credential requirements established by law and of professional liability insurance in the amounts required by the coordinated care organization;

(3) Peer review of the plan's health care providers, using a review committee the majority of whose members are licensed health care providers including licensed providers with similar types and degrees of expertise as the provider being evaluated;

(4) A quality assurance review committee to ensure appropriate treatment or to prevent inappropriate or excessive treatment, and to improve the quality of medical care, services, and supplies by assessing and making necessary improvements to the quality of medical care, services, and supplies;

(5) A utilization review committee to ensure the appropriate use of resources and maintain the most efficient medical treatment utilization levels by monitoring laboratory and diagnostic imaging utilization, hospital length of stay, and prescribing patterns;

(6) No discrimination against or exclusion from participation in the plan of any category of health care providers and includes an adequate number of each category of health care providers to give injured employees adequate flexibility to choose health care providers from among those individuals who provide services under the plan;

(7) Allowing workers to receive medical care from an attending health care provider who is not a member of the coordinated care organization, but who maintains the injured worker's medical records and with whom the injured worker has a documented history of treatment; provided that the attending health care provider agrees to refer the injured worker to the coordinated care organization for any specialized treatment, and if the attending health care provider agrees to comply with all the rules, terms, and conditions relating to services performed by the coordinated care organization;

(8) Access to workplace safety and injury prevention consultative programs involving workers, employers, insurers, and the coordinated care organization to promote workplace health and safety;

(9) Access to return to work programs and vocational rehabilitation programs for injured workers;

(10) An internal dispute resolution process such as mediation to reduce the adversarial nature of workers' compensation;

(11) Case managers, who are at a minimum, professionally qualified registered nurses, to assist injured workers in receiving timely and appropriate care, assist employers in planning for the injured worker's return to work, and assist insurers in facilitating claims; and

(12) Timely and accurate reporting to the department of medical care, services, and supplies utilization; customer complaints and satisfaction; and costs to enable the department to evaluate the effectiveness of the organization's plan.

(c) Notwithstanding section 386-26, coordinated care organizations shall establish guidelines for treatment and utilization of medical care and services that are necessary to furnish the medical care, services, and supplies for injured workers.

(d) There is established a coordinated care organization special fund to be administered by the department. Sums received by the department for the 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.

§386-B Coordinated care organization; selection. (a) An employer who chooses to furnish all medical care, services, and supplies to injured workers through a coordinated care organization or organizations shall notify employees of eligible health care providers in the selected coordinated care organizations and the manner in which medical services may be received. An employee choosing not to receive medical care from a coordinated care organization shall receive medical care, services, and supplies as provided in part II.

(b) Notwithstanding section 386-21 and except as provided in a collective bargaining agreement negotiated under section 386-3.5, when an employer or insurer of an employer contracts with a coordinated care organization to furnish all medical care, services, and supplies, an injured employee not receiving medical care from an attending health care provider as provided in subsection 386-A(b)(7) or choosing to receive medical care, services, and supplies under part II, shall select an attending health care provider within the coordinated care organization.

(c) An injured employee may receive immediate emergency medical treatment from a health care provider who is not a member of the coordinated care organization. Except when an injured employee chooses to receive medical care from an attending health care provider as provided in subsection 386-A(b)(7) or under part II, after the emergency treatment, the injured employee utilizing a coordinated care organization plan shall select an attending health care provider within the coordinated care organization as soon as reasonably possible.

§386-C Amounts 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 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 chapter 431, article 5. 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 on a fee for each service.

SECTION 2. Section 386-21, Hawaii Revised Statutes, is amended by amending subsection (b) to read as follows:

"(b) [~~Whenever~~] Except as provided in part , whenever medical care is needed, the injured employee may select any physician or surgeon who is practicing on the island where the injury was incurred to render such care. If the services of a specialist are indicated, the employee may select any such physician or surgeon practicing in the State. The director may authorize the selection of a specialist practicing outside the State where no comparable medical attendance within the State is available. Upon procuring the services of such physician or surgeon, the injured employee shall give proper notice of the employee's selection to the employer within a reasonable time after the beginning of the treatment. If for any reason during the period when medical care is needed, the employee wishes to change to another physician or surgeon, the employee may do so in accordance with rules prescribed by the director. If the employee is unable to select a physician or surgeon and the emergency nature of the injury requires immediate medical attendance, or if the employee does not desire to select a physician or surgeon and so advises the employer, the employer shall select the physician or surgeon. Such selection, however, shall not deprive the employee of the employee's right of subsequently selecting a physician or surgeon for continuance of needed medical care."

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. Statutory material to be repealed is bracketed and stricken. New statutory material is underscored.

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

INTRODUCED BY:	_____________________________