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 happens first. 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 before 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 happens first). 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 before 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 noncomplying 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 an 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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