1) WC PPP administrators and insurers must,
in addition to those requirements established in subsection (a):
A) File a description of how health care
services to be rendered under the preferred provider program are reasonably
accessible and available to beneficiaries;
B) File a provision ensuring that, whenever a
covered employee has made a good faith effort to utilize network providers for
a covered service and it is determined the administrator does not have the
appropriate preferred providers due to insufficient number, type or distance,
the administrator shall ensure, directly or indirectly, by terms contained in
the payor contract, that the covered employee will be provided the covered
services by the non-preferred provider in accordance with the fees established
by the Workers' Compensation Fee Schedule. This subsection (b)(1)(B) does not
apply to a covered employee who violates Section
8.1 a(c) and (d) of
the Worker's Compensation Act for health care services available through the
administrator's panel of participating providers. In these circumstances, the
requirements of Section 8.2 of the Workers' Compensation Act for non-preferred
provider reimbursements will apply. This subsection (b)(1)(B) does not apply to
SPPP administrators;
C) File
policies and procedures ensuring, directly or indirectly, that, whenever a
covered employee has made a good faith effort to utilize network providers for
a covered service and it is determined the administrator does not have the
appropriate preferred providers due to insufficient number, type or distance,
the administrator shall ensure, directly or indirectly, by terms contained in
the payor contract, that the covered employee will be provided the covered
services as if they been provided by a preferred provider, without any loss of
provider choice under Section 8 or 8.1a(c) of the Workers' Compensation Act.
This subsection (b)(1)(C) does not apply to a covered employee who violates
Section 8.1a(c) and (d) of the Workers' Compensation Act for health care
services available through the administrator's panel of preferred providers. In
these circumstances, the requirements of Section 8.2 of the Workers'
Compensation Act, including the Workers' Compensation Medical Fee Schedule, for
non-preferred provider reimbursements will apply. This subsection (b)(1)(C)
does not apply to SPPP administrators;
D) Provide geographical maps indicating
primary treating physician and hospital health care services for emergency
health care services, within 30 minutes or 15 miles of each covered employee's
residence;
E) Provide geographical
maps indicating providers of occupational health services and specialists
within 60 minutes or 30 miles of a covered employee's residence;
F) If the WC PPP administrator believes that,
given the facts and circumstances with regard to a portion of its service area
(specifically rural areas, including those in which health facilities are
located at least 30 miles apart), the accessibility standards set forth in
subsections (b)(1)(D) and/or (E) are unreasonably restrictive, the
administrator shall include proposed alternative standards in writing in its
application or in a notice of program modification. The alternative standards
shall provide that all services shall be available and accessible at reasonable
times to all covered employees;
G)
Coverage Outside the PPP
i) Provide written
policy for arranging or approving non-emergency medical care for:
* A covered employee authorized by the employer to temporarily
work or travel for work outside the preferred provider program geographic
service area when the need for medical care arises;
* A former employee whose employer has ongoing workers'
compensation obligations and who permanently resides outside the preferred
provider program geographic service area; and
* A covered employee who decides to temporarily reside outside
the preferred provider program geographic service area during recovery.
ii) In the written policy, provide
covered employees described in subsection (b)(1)(G)(i) with the choice of at
least three providers outside the PPP geographic service area who either have
been referred by the covered employee's primary treating physician within the
PPP or have been selected by the WC PPP administrator. The referred providers
shall be located within the access standards described in subsections (b)(1)(D)
and (E);
H) For
non-emergency services:
i) Ensure that an
appointment for initial treatment is available within 3 business days after the
WC PPP administrator's receipt of a request for treatment within the
PPP.
ii) For treatment of common
injuries experienced by covered employees, based on the type of occupation or
industry in which the covered employee is engaged, ensure that an appointment
is available within 20 business days after the WC PPP administrator's receipt
of a referral to a specialist within the PPP.
2) For purposes of subsection (b)(1)(G),
nothing precludes a WC PPP administrator from having a written policy that
allows a covered employee outside the preferred provider program geographic
service area to choose his or her own provider for non-emergency medical care.
This Section does not apply to SPPP administrators.