Of all the medical cost-containment measures enacted in the amendment of KRS 342.020 in 1994, managed care is of the most historical significance. For the first time employers are granted input into the matter of physician selection through managed care plans approved by the commissioner. Employees still have choice of physician but within the confines of the provider network. (803 KAR 25:110) The Administrative Regulation establishing the standards for managed care plans was adopted on July 15, 1994. The first plan was approved in October and by November 1994, Kentucky workers were being treated under approved plans. Managed care emphasizes controlling utilization through gatekeeper physicians, pre-certification of services, strong case management and coordination of medical treatment and return-to-work policies. Internal grievance procedures are required. Managed care affords insuring interests a strong voice in selecting network providers and results in the exclusion of some physicians from the workers compensation process whose practice patterns have proven to be outside of the norm as to utilization or outcomes.
Any managed care system may file a managed care plan for approval with the commissioner for the Department of Workers' Claims. Systems may operate more than one managed care plan. Employers and insurers may contract with multiple systems in order to maximize employee access. There is no application form nor application fee. Applications for certification must contain all the components of the regulation.
Plans are reviewed for compliance with the regulation. Some of the key requirements are:
- Identify the system and its components. Identify the key personnel including plan administrator, medical director (must have a Kentucky medical license) and case manager (must hold Kentucky certification).
- Demonstrate financial ability and professional expertise to perform all necessary functions. If applicants have previously provided managed care or similar services in the commonwealth, they must provide a summary of the administrative and medical services provided and a list of representative entities. If the applicant does not provide managed care in Kentucky, a performance bond or cash surety deposit of $500,000 will be required. A copy of the most recent audited financial statement is also required.
- The plan must demonstrate it will provide prompt and effective access to qualified medical services. The employees must have adequate choice and convenient geographic access to gatekeepers, specialists and facilities.
- Maintain a professional malpractice policy with limits of no less than $500,000 for an occurrence of professional negligence.
Conditions pre-requisite to out-of-plan provider access are:
- Emergency. Emergency means those medical services required for the immediate diagnosis or treatment of a medical condition that if not immediately diagnosed or treated could lead to serious physical or mental disability or death, or medical services that are immediately necessary to alleviate severe pain. "Emergency care" does not include follow-up care, except when immediate care is required to avoid serious disability or death. Employees who receive emergency care may elect to remain under the care of that physician as long as he or she complies with the utilization review and reporting requirements of the plan. Reimbursement of the non-plan providers will be at the level prescribed by applicable workers' compensation fee schedules.
- When referred by gatekeeper.
- When authorized treatment is unavailable within the plan.
- For a second opinion when surgery is recommended.
- When treatment is received for a work-related injury or disease prior to the plan being implemented with that employer, an employee may continue with that physician until treatment ends or until he or she changes physicians. Then the employee must choose a physician within the plan.
The plan must have the following:
Provide specimens of information materials and a toll-free phone number available 24 hours a day to inform all parties about plan operations, after-office-hours care and 24-hour access to emergency care.
Provide aggressive case management to coordinate the delivery of health services and return-to-work policies to promote an appropriate, prompt return to work and facilitate communication among the employee, employer and health care providers. The plan shall also describe the circumstances under which injured employees shall be subject to case management and the services to be provided.
To review 803 KAR 25:110, click here
For more information, please contact Marilyn Benham, Managed Care, Department of Workers' Claims, 502-782-4539; e-mail Marilyn.Benham@ky.gov