Workers' Compensation Network Availability and Adequacy Requirements

Section 2051.315  Workers' Compensation Network Availability and Adequacy Requirements a)         WC PPP administrators and insurers must file a description of the services to be offered through a WC PPP. The description shall include: 1)         The method of marketing the program; 2)         A geographic map of the area proposed to be served by the program by county and zip code, including marked locations for preferred providers; 3)         The names, addresses and specialties of the providers who have entered into preferred provider agreements under the program; 4)         The number of beneficiaries estimated to be covered by the providers listed in subsection (a)(3); 5)         An Internet website and toll-free telephone number for insureds, beneficiaries and prospective beneficiaries to access up-to-date lists of preferred providers, as well as any other information necessary to conform to this Part. A WC PPP shall identify specific providers in a beneficiary's area, confirm specific provider participation or provide a listing of specific preferred providers in the delivery mode requested by the beneficiary. Preferred provider lists requested by phone must be sent within 3 working days. The up-to-date provider list applies to all providers that have entered arrangements to provide services directly under the program or indirectly through another administrator. WC PPP administrators' and insurers' Internet website addresses shall be prominently displayed on all advertisements, marketing materials and brochures; 6)         A description of how health care services to be rendered under the preferred provider program are reasonably accessible and available to beneficiaries. Standards shall address: A)        The type of health care services to be provided by the administrator; B)        The ratio of providers to beneficiaries, by specialty and including primary treating physicians, when applicable under the contract, necessary to meet the health care needs and service demands of the estimated covered employees; C)        Written policies and procedures for determining when the program is closed to new providers desiring to enter into preferred provider arrangements; D)        Written policies and procedures for adding providers to meet patient needs based on increases in the number of beneficiaries, changes in the patient to provider ratio, changes in medical and health care capabilities, and increased demand for services; E)        If applicable, procedures for making referrals within and outside the network; F)         Efforts to address the needs of beneficiaries with limited English proficiency and literacy and/or diverse cultural and ethnic backgrounds, and to comply with the Americans With Disabilities Act of 1990; 7)         If a WC PPP administrator is leasing, buying or otherwise using another administrator's or insurer's program and the required information has previously been filed by the other administrator or insurer, only the administrative agreement and verification that the providers have consented to the agreement pursuant to Section 2051.300(d) need to be filed. A clause within the provider contract allowing assignment will be deemed consent in the absence of material modification of the provider's obligations under the contract; and 8)         A statement that covered employees are not responsible for any costs associated with medical record transmission or duplication in order to have a claim adjudicated. b)         Additional Requirements 1)         WC PPP administrators and insurers must, in addition to those requirements established in subsection (a): A)        File a description of how health care services to be rendered under the preferred provider program are reasonably accessible and available to beneficiaries; B)        File a provision ensuring that, whenever a covered employee has made a good faith effort to utilize network providers for a covered service and it is determined the administrator does not have the appropriate preferred providers due to insufficient number, type or distance, the administrator shall ensure, directly or indirectly, by terms contained in the payor contract, that the covered employee will be provided the covered services by the non-preferred provider in accordance with the fees established by the Workers' Compensation Fee Schedule.  This subsection (b)(1)(B) does not apply to a covered employee who violates Section 8.1a(c) and (d) of the Worker's Compensation Act for health care services available through the administrator's panel of participating providers.  In these circumstances, the requirements of Section 8.2 of the Workers' Compensation Act for non-preferred provider reimbursements will apply.  This subsection (b)(1)(B) does not apply to SPPP administrators; C)        File policies and procedures ensuring, directly or indirectly, that, whenever a covered employee has made a good faith effort to utilize network providers for a covered service and it is determined the administrator does not have the appropriate preferred providers due to insufficient number, type or distance, the administrator shall ensure, directly or indirectly, by terms contained in the payor contract, that the covered employee will be provided the covered services as if they been provided by a preferred provider, without any loss of provider choice under Section 8 or 8.1a(c) of the Workers' Compensation Act.  This subsection (b)(1)(C) does not apply to a covered employee who violates Section 8.1a(c) and (d) of the Workers' Compensation Act for health care services available through the administrator's panel of preferred providers.  In these circumstances, the requirements of Section 8.2 of the Workers' Compensation Act, including the Workers' Compensation Medical Fee Schedule, for non-preferred provider reimbursements will apply.  This subsection (b)(1)(C) does not apply to SPPP administrators; D)        Provide geographical maps indicating primary treating physician and hospital health care services for emergency health care services, within 30 minutes or 15 miles of each covered employee's residence; E)        Provide geographical maps indicating providers of occupational health services and specialists within 60 minutes or 30 miles of a covered employee's residence; F)         If the WC PPP administrator believes that, given the facts and circumstances with regard to a portion of its service area (specifically rural areas, including those in which health facilities are located at least 30 miles apart), the accessibility standards set forth in subsections (b)(1)(D) and/or (E) are unreasonably restrictive, the administrator shall include proposed alternative standards in writing in its application or in a notice of program modification.  The alternative standards shall provide that all services shall be available and accessible at reasonable times to all covered employees; G)        Coverage Outside the PPP i)          Provide written policy for arranging or approving non-emergency medical care for: •           A covered employee authorized by the employer to temporarily work or travel for work outside the preferred provider program geographic service area when the need for medical care arises; •           A former employee whose employer has ongoing workers' compensation obligations and who permanently resides outside the preferred provider program geographic service area; and •           A covered employee who decides to temporarily reside outside the preferred provider program geographic service area during recovery. ii)         In the written policy, provide covered employees described in subsection (b)(1)(G)(i) with the choice of at least three providers outside the PPP geographic service area who either have been referred by the covered employee's primary treating physician within the PPP or have been selected by the WC PPP administrator. The referred providers shall be located within the access standards described in subsections (b)(1)(D) and (E); H)        For non-emergency services: i)          Ensure that an appointment for initial treatment is available within 3 business days after the WC PPP administrator's receipt of a request for treatment within the PPP. ii)         For treatment of common injuries experienced by covered employees, based on the type of occupation or industry in which the covered employee is engaged, ensure that an appointment is available within 20 business days after the WC PPP administrator's receipt of a referral to a specialist within the PPP. 2)         For purposes of subsection (b)(1)(G), nothing precludes a WC PPP administrator from having a written policy that allows a covered employee outside the preferred provider program geographic service area to choose his or her own provider for non-emergency medical care. This Section does not apply to SPPP administrators.