Tony Guidone 503-934-6018, or call Sandra Savage at 503-934-6023
Managed
care organization -
subjectivity and enrollment of workers
To
determine if a worker could be subject to a managed care organization (MCO) contract,
first ask if the worker's employer is covered by an insurer who has a contract with an
MCO (or, if the worker's employer is self-insured, ask if the self-insured employer has
a contract with an MCO). Worker subjectivity is tied to the worker's place of employment.
Next, ask if the MCO is approved to operate in the geographic
service area (GSA) where the worker's employer is located. If the answer to both
questions is yes, and the insurer appropriately notified the worker of his or her enrollment
in the MCO, the worker is subject to the MCO. A worker is subject to the MCO when he
or she receives written notice of enrollment from the insurer, or upon the third day
after the insurer mailed the written notice to the worker, whichever first occurs. However,
the enrollment notice must be complete and provide all required
enrollment information.
If a worker's primary residence is more than 100 miles outside the MCO's authorized
GSA, the worker is not subject to the managed care contract [ORS
656.245(4)(a)]. However, an insurer may enroll a worker who lives within 100 miles
outside the MCO's authorized GSA. A subject worker must be able to access MCO medical
providers within a reasonable distance from the worker's place of employment [OAR
436-015-0030(3)(h)]. When an enrolled worker lives outside the MCO's authorized GSA,
the worker may treat with a non-MCO provider who practices closer to the worker's residence
as long as that provider agrees to comply with the MCO's terms and conditions. But, if
there is an MCO panel provider (of the same category as the non-MCO panel provider) located
closer to the worker's residence than the non-MCO provider, the enrolled worker must
treat with the MCO provider [OAR 436-015-0030(3)(h)].
Insurers may enroll workers receiving medical treatment for an accepted claim, regardless
of the worker's date of injury or medically stationary status. However, if the worker
is not medically stationary at time of enrollment, the insurer
must notify the worker of his or her right to request a review by the MCO if the worker
believes that changing providers would be medically detrimental [ORS
656.245(4)(a) and OAR 436-010-0275(6)].
Insurers may choose to enroll a worker in an MCO prior to claim acceptance. The insurer's
enrollment letter to the worker must explain that the insurer will pay for all reasonable
and necessary medical services received by the worker that are not otherwise covered
by health insurance, even if the insurer denies the claim, until the worker receives
actual notice of the denial or until three days after the insurer mails the denial to
the worker (whichever first occurs). If the worker chooses to treat with a non-panel
primary care physician or authorized nurse practitioner who
agreed to the terms and conditions of the MCO, payment of medical services is not guaranteed
[ORS 656.245(4)(b)(B)].
If a worker chooses to treat within the MCO prior to enrollment, the insurer or self-insured
employer is not obligated to pay for the worker's medical services unless the insurer
or self-insured employer later accepts the worker's claim [ORS
656.245(4)(b)(C)].
If a worker's claim is denied, the worker may treat outside the MCO after the date of
denial until if or when the denial is reversed. If the claim is finally determined to
be compensable, the insurer or self-insured employer must pay for all reasonable and
necessary medical services received by the worker from sources outside the MCO [ORS
656.245(4)(b)(D)].
A worker of a non-complying employer may be subject (after appropriate enrollment notification)
to a contract between the assigned claims agent and an MCO [ORS
656.245(4)(a)].
If a MCO contract expires or terminates without renewal, a worker is no longer subject
to that contract. When this occurs, insurers must provide written
notification to workers informing them they are no longer subject to the contract
[ORS 656.245(4)(a) and OAR
436-010-0275(13)]. A worker may become subject to a subsequent managed care contract.
Should this happen, the worker may choose to continue treating with his or her attending
physician or authorized nurse practitioner under the expired or terminated contract,
as long as that attending physician or authorized nurse practitioner agree to comply
with the rules, terms, and conditions of the subsequent MCO [ORS
656.245(4)(a)].
If you have questions about this webpage, please contact Tony Guidone, 503-934-6018, or call Sandra Savage at 503-934-6023.
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