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Teri Watson
503-947-7697
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Managed
care organization -
subjectivity and enrollment of workers
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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)].
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If you have questions about this webpage, please contact Teri Watson, 503-947-7697.
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