§ 85A-64. Certification of workplace medical plan.

A.  Any person or entity may make written application to the State Commissioner of Health to have a workplace medical plan certified that provides management of quality treatment to injured employees for injuries and diseases compensable under this act.  Each application for certification shall be accompanied by a fee of One Thousand Five Hundred Dollars ($1,500.00).  A workplace medical plan may be certified to provide services to a limited geographic area.  A certificate is valid for a five-year period, unless revoked or suspended.  Application for certification shall be made in the form and manner and shall set forth information regarding the proposed program for providing services as the State Commissioner of Health may prescribe.  The information shall include, but not be limited to:

1.  A list of the names of all medical providers who shall provide services under the plan, together with appropriate evidence of compliance with any licensing or certification requirements for those providers to practice in this state; and

2.  A description of the places and manner of providing services under the plan.

B.  The State Commissioner of Health shall not certify a plan unless he or she finds that the plan:

1.  Proposes to provide quality services for all medical services which:

a.may be required by this act in a manner that is timely, effective and convenient for the employee, and

b.utilize medical treatment guidelines and protocols consistent with those established by the Official Disability Guidelines;

2.  Is reasonably geographically convenient to residents of the area for which it seeks certification;

3.  Provides appropriate financial incentives to reduce service costs and utilization without sacrificing the quality of service;

4.  Provides adequate methods of peer review, utilization review and dispute resolution to prevent inappropriate, excessive or medically unnecessary treatment, and excludes participation in the plan by those providers who violate these treatment standards;

5.  Provides aggressive case management for injured employees and a program for early return to work;

6.  Provides a timely and accurate method of reporting to the State Commissioner of Health necessary information regarding medical service costs and utilization to enable the State Commissioner of Health to determine the effectiveness of the plan;

7.  Authorizes necessary emergency medical treatment for an injury provided by a provider of medical, surgical, and hospital services who is not a part of the plan; and

8.  Does not discriminate against or exclude from participation in the plan any category of providers of medical, surgical, or hospital services and includes an adequate number of each category of providers of medical, surgical, and hospital services to give participants access to all categories of providers and does not discriminate against ethnic minority providers of medical services.

C.  The State Commissioner of Health may accept findings, licenses or certifications of other state agencies as satisfactory evidence of compliance with a particular requirement of this section.

D.  Except for self-insured employers, if any insurer does not contract with or provide access to a certified workplace medical plan, an insured, after sixty (60) days' written notice to its insurance carrier, shall be authorized to contract independently with a plan of his or her choice for a period of one (1) year, to provide medical care under this act.  The insured shall be authorized to contract, after sixty (60) days' written notice to its insurance carrier, for additional one-year periods if the insurer has not contracted with or provided access to a certified workplace medical plan.

E.  If an employer is not experience-rated when it participates in a certified workplace medical plan, its workers' compensation insurer shall grant a ten-percent premium reduction.

F.  The State Commissioner of Health shall refuse to certify or shall revoke or suspend the certification of a plan if the State Commissioner of Health finds that the program for providing medical or health care services fails to meet the requirements of this section, or service under the plan is not being provided in accordance with the terms of the plan.

G.  The State Commissioner of Health shall implement a site visit protocol for employees of the State Department of Health to perform an inspection of a certified workplace medical plan to ensure that medical services to an employee and the medical management of the employee's needs are adequately met in a timely manner and that the certified workplace medical plan is complying with all other applicable provisions of this act and the State Department of Health.  This protocol shall include, but not be limited to:

1.  A site visit shall be made to each certified workplace medical plan not less often than once every year, but not later than thirty (30) days following the anniversary date of issuance of the initial or latest renewal certificate;

2.  A site visit shall determine whether or not a certified workplace medical plan is operating in accordance with its latest application to the State Department of Health;

3.  Compliant operations shall include, but not be limited to:

a.timely and effective medical services available with reasonable geographic convenience,

b.treatment guidelines and protocols consistent with the Official Disability Guidelines, and

c.effective programs for utilization review, case management, grievances, and dispute resolution;

4.  Performance of a site visit shall include:

a.inspection of organizational documentation,

b.inspection of systems documentation and processes,

c.random or systematic sampling of closed and open case management cases,

d.workplace medical plan employee and management interviews, as appropriate;

5.  An initial site visit may occur with an interval of less than twelve (12) months to a recently certified plan, or a site visit may occur more often than once in every twelve (12) months if the State Commissioner of Health has reason to suspect that a plan is not operating in accordance with its certification;

6.  If a deficient practice is identified during a site visit, the State Department of Health shall require a certified workplace medical plan to submit a timely and acceptable written plan of correction, and then may perform a follow-up visit or visits to ensure that the deficient practice has been eliminated;

7.  If a deficient practice is not remedied by a certified workplace medical plan on a timely basis, the State Commissioner of Health shall revoke or suspend the certification of the plan;

8.  In addition to the certification fee required pursuant to subsection A of this section, certified workplace medical plans shall pay the State Department of Health:

a.One Thousand Five Hundred Dollars ($1,500.00) for an initial annual site visit, and

b.One Thousand Dollars ($1,000.00) for each follow-up visit, but only if less than two site visits occur in a twelve-month period; and

9.  In addition to the site visit fee required pursuant to paragraph 8 of this subsection, employees of the State Department of Health may charge to the certified workplace medical plan reasonable travel and travel-related expenses for the site visit such as overnight lodging and meals.  A certified workplace medical plan shall reimburse travel expenses to the State Department of Health at rates equal to the amounts then currently allowed under the State Travel Reimbursement Act.

I.  The State Board of Health shall adopt such rules as may be necessary to implement the provisions of this section.  Such rules shall authorize any person to petition the State Commissioner of Health for decertification of a certified workplace medical plan for a material violation of any rules promulgated pursuant to this section.

Added by Laws 2013, c. 208, § 64, eff. Feb. 1, 2014.