Report Title:
Employee Care Systems
Description:
Permits employee care systems to furnish medical care, services, and supplies to injured workers. (HB1783 HD1)
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HOUSE OF REPRESENTATIVES |
H.B. NO. |
1783 |
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TWENTY-THIRD LEGISLATURE, 2005 |
H.D. 1 |
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STATE OF HAWAII |
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A BILL FOR AN ACT
relating to employee care systems.
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 . EMPLOYEE CARE SYSTEMS
§386-A Purpose. (a) A system of coordinated care for injured employees 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 employee care system under section 386-K;
(2) Provide efficient, cost effective, and timely treatment for injured employees through a coordinated and comprehensive system of quality health care, including the use of case management;
(3) Provide employees with a choice to elect treatment for workplace injuries under an employee care system, or as otherwise provided under this chapter;
(4) Provide a high level of quality of care;
(5) 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 employee care system;
(6) Provide a range of treatment, including but not limited to office, clinic, laboratory, hospital, rehabilitative, emergency, and other essential care;
(7) 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;
(8) 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;
(9) Provide a vocational rehabilitation program under section 386-25; and
(10) 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 an employee care system registered under section 386-D in forming a system of coordinated care and to assist the employer, the employer's workers' compensation insurer, or a collective bargaining unit in selecting an employee care system.
(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 agreement of the employer and employee. If the employee is represented by a collective bargaining representative, this part shall not apply without the mutual authorization of the collective bargaining representative and the employer.
(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 employee care system to provide coverage for medical and rehabilitative services required under this chapter.
(c) For an employer not subject to collective bargaining, the employer or the employer's workers' compensation insurer or the employer's employer association may contract with an employee care system registered under section 386-D(a) to provide medical and rehabilitative services required under this chapter. For purposes of this subsection, employer associations may contract for medical and rehabilitative services required under this chapter through employee care systems formed under section 386-C.
As used in this subsection, "employer associations" means any legal association of individuals, corporations, partnerships, or associations, except labor organizations, formed for purposes other than insurance.
(d) Captive insurers licensed under chapter 431:19 and self-insureds under section 386-121 may contract with an employee care system registered under section 386-D(a) to provide medical and rehabilitative services required under this chapter.
§386-C Who may form. (a) The following groups may form an employee care system for purposes of section 386-B:
(1) A mutual benefit society certified under chapter 432;
(2) A labor organization, as defined in section 386-8.5(a)(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 this chapter.
§386-D Registration. (a) An employee care system 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 employee care system;
(2) Identity of members of the employee care system, including but not limited to health care providers, clinics, and hospitals or other medical facilities;
(3) Services provided by the employee care system; 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 employee care system that does not meet the requirements of section 386-C.
(c) An employee care system 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 Solvency and fee schedules. (a) A registered employee care system 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 employee care system 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) A labor organization under section 386-C(a)(2) or an association under section 386-C(a)(5) shall post bond with the insurance commissioner in an amount that the commissioner deems sufficient.
(c) An employee care system 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 fee for each service.
(d) Fee schedules shall be as provided under section 386-21(c).
(e) If an employee disenrolls from an employee care system under section 386-G(d), the employee care system under a fixed sum amount under subsection (b) may retain the earned payment up to the end of the month of the disenrollment and need not refund the earned payment.
§386-F Treatment and utilization protocols. (a) A registered employee care system 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 employee care system 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 employee care system shall utilize the procedures under section 386-A(a)(10) 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-G Choice of employee care system; choice of provider. (a) An employer may select two or more registered employee care systems 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 an employee care system under subsection (a), the employer shall provide the employee with information about each employee care system 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 employee care system.
(c) A registered employee care system shall provide to an employee in its program a choice of physicians and specialists. The employee may change a physician or a specialist within the same employee care system under the guidelines provided in section 386-21(b).
(d) After a definitive diagnosis or three visits, whichever occurs first, within an employee care system for a work injury during the period of enrollment, the employee shall first obtain the approval of either the director or employer in order to change a physician, hospital, or specialist to one outside of the employee care system. Such changes in physician, hospital, or specialist to one outside of the employee care system shall be deemed to be a disenrollment from the employee care system. An employee who disenrolls may enroll in another registered employee care system offered by the employer, or the employee may select any health care provider for treatment for a work injury. Any further change of physicians, hospitals, or specialists for the disenrolled employee shall require the prior approval of the employer.
(e) 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.
(f) This section shall not be construed to affect section 386-21(b) with regards to changing a provider.
§386-H Compensation. An employee who enrolls in an employee care system under this part who suffers from a work injury that causes total disability shall be compensated under the guidelines provided in section 386-31, except that the employer shall pay the injured employee a weekly benefit at the rate of sixty-six and two-thirds per cent of the employee's average weekly wages beginning on the first day of the confirmed disability.
§386-I Independent medical examination. (a) The employer, the employer's workers' compensation insurer, or the injured worker may request an independent medical examination for good cause. A case manager under section 386-K shall refer the injured worker to an appropriate health care provider for an independent medical examination outside of the employee care system. 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 employee care system 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's workers' compensation insurer or the 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 employee care system, the employer, the employer's workers' compensation insurer, and the employee.
§386-J Case management. A registered employee care system 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 employee care system.
§386-K Workplace health and safety. (a) An employer under section 386-B(b) or (c) shall have a program of workplace health and safety, as follows:
(1) For each employer with more than ten employees, there shall be a safety committee; and
(2) For each employer with ten or fewer employees, there shall be a safety committee if:
(A) The employer has a lost workday cases incidence rate in the top ten per cent of all rates for employers in the same industry; or
(B) The workers' compensation premium classification assigned to the greatest portion of the payroll for the employer has a premium rate in the top twenty-five per cent of premium rates for all classes as approved by the director; provided that the director shall use the most recent departmental statistics regarding occupational injuries and illnesses and workers' compensation loss cost rates approved for use in this State.
(b) A safety committee under subsection (a) shall have a membership that has an equal number of employee and employer representatives who are volunteers for membership and who are selected by their respective peers. A safety committee shall have the following duties:
(1) To have a regular meeting schedule; provided that each meeting shall be recorded in writing by the employer who shall maintain these records for inspection by the director; provided further that the employer shall compensate employee representatives for the time in attending meetings or the time in attending safety committee training, at the regular hourly rate;
(2) To inspect the workplace for health and safety on a regular basis;
(3) To investigate each incidence of accident, illness, or death in the workplace; and
(4) To prescribe guidelines for the training of safety committee members."
SECTION 2. Section 386-31, Hawaii Revised Statutes, is amended by amending subsection (b) to read as follows:
"(b) Temporary total disability. [Where] Except as otherwise provided in this chapter, where a work injury causes total disability not determined to be permanent in character, the employer, for the duration of the disability, but not including the first three calendar days thereof, shall pay the injured employee a weekly benefit at the rate of sixty-six and two-thirds per cent of the employee's average weekly wages, subject to the limitations on weekly benefit rates prescribed in subsection (a), or if the employee's average weekly wages are less than the minimum weekly benefit rate prescribed in subsection (a), at the rate of one hundred per cent of the employee's average weekly wages.
The employer shall pay temporary total disability benefits promptly as they accrue to the person entitled thereto without waiting for a decision from the director, unless such right is controverted by the employer in the employer's initial report of industrial injury. The first payment of benefits shall become due and shall be paid no later than on the tenth day after the employer has been notified of the occurrence of the total disability, and thereafter the benefits due shall be paid weekly except as otherwise authorized pursuant to section 386-53.
The payment of such benefits shall only be terminated upon order of the director or if the employee is able to resume work. When the employer is of the opinion that temporary total disability benefits should be terminated because the injured employee is able to resume work, the employer shall notify the employee and the director in writing of an intent to terminate such benefits at least two weeks prior to the date when the last payment is to be made. The notice shall give the reason for stopping payment and shall inform the employee that the employee may make a written request to the director for a hearing if the employee disagrees with the employer. Upon receipt of the request from the employee, the director shall conduct a hearing as expeditiously as possible and render a prompt decision as specified in section 386-86.
An employer or insurance carrier who fails to comply with this section shall pay not more than $2,500 into the special compensation fund upon the order of the director, in addition to other penalties prescribed in section 386-92.
(1) In any case where the director determines based upon a review of medical records and reports and other relevant documentary evidence that an injured employee's medical condition may be stabilized and the employee is unable to return to the employee's regular job, the director shall issue a preliminary decision regarding the claimant's entitlement and limitation to benefits and rights under Hawaii's workers' compensation laws. The preliminary decision shall be sent to the affected employee and the employee's designated representative and the employer and the employer's designated representative and shall state that any party disagreeing with the director's preliminary findings of medical stabilization and work limitations may request a hearing within twenty days of the date of the decision. The director shall be available to answer any questions during the twenty-day period from the injured employee and affected employer. If neither party requests a hearing challenging the director's finding the determination shall be deemed accepted and binding upon the parties. In any case where a hearing is held on the preliminary findings, any person aggrieved by the director's decision and order may appeal under section 386-87.
A preliminary decision of the director shall inform the injured employee and the employer of the following responsibilities, benefits, and limitations on vocational rehabilitation benefits which are designed to facilitate the injured employee's early return to suitable gainful employment:
(A) That the injured employee may invoke the employee's rights under section 378-2, 378-32, or 386-142, or all of them, in the event of unlawful discrimination or other unlawful employment practice by the employer.
(B) That after termination of temporary total disability benefits an injured employee who resumes work may be entitled to permanent partial disability benefits, which if awarded, shall be paid regardless of the earnings or employment status of the disabled employee at the time.
(2) In any case in which the rehabilitation unit determines that an injured employee is not a feasible candidate for rehabilitation and that the employee is unable to resume the employee's regular job, it shall promptly certify the same to the director. Soon thereafter, the director shall conduct a hearing to determine whether the injured employee remains temporarily totally disabled, or whether the employee is permanently partially disabled, or permanently totally disabled."
SECTION 3. (a) There is established an employee care system 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: labor, management, employee care systems, health care providers involved with an employee care system, 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 employee care 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 employee care system in achieving the purposes set forth under section 386-A, Hawaii Revised Statutes;
(3) Make recommendations, if any, to strengthen the employee care system;
(4) Compare workers' compensation insurance premiums paid by employers before and after utilizing employee care systems; and
(5) Make a recommendation to the legislature as to whether the repeal date of June 30, 2009, for this Act should be extended.
The department of labor and industrial relations shall provide staff support to the task force and otherwise assist the task force in gathering information and data for the study.
(c) All registered employee care systems shall cooperate with the task force in the study by providing information to the task force or the department of labor and industrial relations upon request. The information shall include the number of employees enrolled in the employee care system, 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 2009.
SECTION 4. The department of labor and industrial relations shall conduct a study of employee care systems. The study shall be completed and a report made to the legislature no later twenty days prior to the convening of the regular session of 2009. The study shall evaluate:
(1) The effectiveness of treatment and quality of care provided by employee care systems;
(2) 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;
(3) The timeliness for injured workers to receive care; and
(4) The extent of implementation of workplace health and safety programs.
The department of labor and industrial relations may order the cooperation of the insurance commissioner, private insurers, and employee care systems to obtain information and statistics in addition to any other sources. Private insurers and employee care systems shall cooperate with the department of labor and industrial relations in its study.
SECTION 5. 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 6. Statutory material to be repealed is bracketed and stricken. New statutory material is underscored.
SECTION 7. This Act shall take effect upon its approval and shall be repealed on June 30, 2009.