Current through Register Vol. 49, No. 13, September 23, 2024
Subpart
1.
Certification.
Except as provided in part
5218.0200, subpart 4, any person
or entity may make written application to the commissioner to provide managed
care to injured employees for injuries and diseases compensable under Minnesota
Statutes, chapter 176, under a plan certified by the commissioner. To obtain
certification of a plan, an application shall be submitted on a form provided
by the commissioner which shall include items A to N, and other matters related
to parts
5218.0010 to
5218.0900.
A. One clean copy suitable for imaging plus
one identical copy of the application must be submitted. Portions of the
application which the managed care plan believes is subject to trade secret
protection under Minnesota Statutes, section
13.37,
must be clearly marked, separated and justified in accordance with part
5218.0800, subpart
2, item B.
B. The plan must provide the information in
subitems (1) to (6). An individual may act in more than one capacity:
(1) the names of all directors and officers
of the managed care plan;
(2) the
title and name of the person to be the day-to-day administrator of the managed
care plan;
(3) the title and name
of the person to be the administrator of the financial affairs of the managed
care plan;
(4) the name, and
medical specialty, if any, of the medical director;
(5) the name, address, and telephone number
of a communication liaison for the department, the insurer, the employer, and
the employee; and
(6) the name of
any entity, other than individual health care providers, with whom the managed
care plan has a joint venture or other agreement to perform any of the
functions of the managed care plan, and a description of the specific functions
to be performed by each entity.
C. Each application for certification or
application following revocation must be accompanied by a nonrefundable fee of
$1,500. If a plan has been provisionally certified under chapter 5218
[Emergency], the application fee shall be $600. Fees for the annual report and
changes to the plan as certified are in part
5218.0300.
D. The managed care plan must ensure
provision of quality services that meet all uniform treatment standards adopted
by the commissioner under Minnesota Statutes, section
176.83, subdivision 5, and
all medical and health care services that may be required by Minnesota
Statutes, chapter 176.
E. The
managed care plan must provide a description of the times, places, and manner
of providing services under the plan, including a statement describing how the
plan will ensure an adequate number of each category of health care providers
is available to give employees convenient geographic accessibility to all
categories of providers and adequate flexibility to choose health care
providers from among those who provide services under the plan, in accordance
with this chapter and Minnesota Statutes, section
176.1351,
subdivisions 1, clauses (1) and (2), and 10.
(1) The managed care plan must include at a
minimum, and provide to an employee when necessary under Minnesota Statutes,
section
176.135,
subdivision 1, the following types of health care services and providers,
unless the managed care plan provides evidence that a particular service or
type of provider is not available in the community:
(a) medical doctors, including the following
specialties:
i. specialists in at least one
of the following fields: family practice, internal medicine, occupational
medicine, or emergency medicine;
ii. orthopedic surgeons, including
specialists in hand and upper extremity surgery;
iii. neurologists and neurosurgeons;
and
iv. general surgeons;
(b) chiropractors;
(c) podiatrists;
(d) osteopaths;
(e) physical and occupational
therapists;
(f) psychologists or
psychiatrists;
(g) diagnostic
pathology and laboratory services;
(h) radiology services; and
(i) hospital, outpatient surgery, and urgent
care services.
The managed care plan must submit copies of all types of
agreements with providers who will deliver services under the managed care
plan, and a description of any other relationships with providers who may
deliver services to a covered employee. The managed care plan must attach to
each standard document a corresponding list of names, clinics, addresses, and
types of license and specialties for the health care providers. The managed
care plan must also submit a statement that all licensing requirements for the
providers are current and in good standing in Minnesota or the state in which
the provider is practicing.
(2) The managed care plan must provide for
referral for specialty services that are not specified in subitem (1) and that
may be reasonable and necessary to cure or relieve an employee of the effects
of the injury under Minnesota Statutes, section
176.135,
subdivision 1. The insurer remains liable for any health service required under
Minnesota Statutes, section
176.135,
that the managed care plan does not provide.
F. The managed care plan must include
procedures to ensure that employees will receive services in accordance with
subitems (1) to (7):
(1) Employees must
receive initial evaluation by a participating licensed health care provider
within 24 hours of the employee's request for treatment, following a work
injury.
(2) In cases where the
employee has received treatment for the work injury by a health care provider
outside the managed care plan under part
5218.0500, subpart
1, item A, the employee must
receive initial evaluation or treatment by a participating licensed health care
provider within five working days of the employee's request for a change of
doctor, or referral to the managed care plan.
(3) Following the initial evaluation, upon
request, the employee must be allowed to receive ongoing treatment from any
participating health care provider as the employee's primary treating health
care provider in one of the disciplines in units (a) to (e), if the provider is
available within the mileage limitations in subitem (7) and the treatment is
required under Minnesota Statutes, section
176.135,
subdivision 1, is within the provider's scope of practice, and is appropriate
under the standards of treatment adopted by the managed care plan or the
standards of treatment adopted by the commissioner under Minnesota Statutes,
section
176.83, subdivision 5:
(a) medical doctors;
(b) chiropractors;
(c) podiatrists;
(d) osteopaths; or
(e) dentists.
An evaluating provider may also be offered as a primary
treating provider.
(4) Employees must receive any necessary
treatment, diagnostic tests, or specialty services in a manner that is timely,
effective, and convenient for the employee.
(5) Employees must be allowed to change
primary treating providers within the managed care plan at least once without
proceeding through the managed care plan's dispute resolution process. In such
cases, employees must make a request to the managed care plan for a change in
their treating health care provider. A change of providers from the evaluating
health care provider in subitems (1) and (2) to a primary treating doctor for
ongoing treatment is not considered a change of doctor, unless the employee has
received treatment from the evaluating health care provider more than once for
the injury.
(6) Employees must be
able to receive information on a 24-hour basis regarding the availability of
necessary medical services available within the managed care plan. The
information may be provided through recorded toll-free telephone messages after
normal working hours. The message must include information on how the employee
can obtain emergency services or other urgently needed care and how the
employee can access an evaluation within 24 hours of the injury as required
under unit (a).
(7) Employees must
have access to the evaluating and primary treating health care provider within
30 miles of either the employee's place of employment or residence if either
the residence or place of employment is within the seven-county metropolitan
area. The seven-county metropolitan area includes Anoka, Carver, Dakota,
Hennepin, Ramsey, Scott, and Washington counties. If both the employee's
residence and place of employment are outside the seven-county metropolitan
area, the allowable distance is 50 miles. If the employee requires specialty
services that are not available within the stated mileage restriction, the
managed care plan may refer the employee to a provider outside of the stated
mileage restriction. If the employee is medically unable to travel to a
participating provider within the stated mileage restriction, the managed care
plan shall refer the employee to an available nonparticipating provider to
receive necessary treatment for the injury.
G. The managed care plan must designate the
procedures for approval of services from a health care provider outside the
managed care plan according to part
5218.0500.
H. The managed care plan must include a
procedure for peer review and utilization review as specified in part
5218.0750.
I. The managed care plan must include a
procedure for internal dispute resolution according to part
5218.0700 and Minnesota Statutes,
section
176.1351,
subdivision 2, clause (4), including a method to resolve complaints by injured
employees, medical providers, and insurers.
J. The managed care plan must describe how
employers and insurers will be provided with information that will inform
employees of all choices of medical service providers within the plan and how
employees can gain access to those providers. The plan must submit a proposed
notice to employees, which may be customized according to the needs of the
employer, but which must include the information in part
5218.0250.
K. The managed care plan must describe how
aggressive medical case management will be provided according to part
5218.0760 for injured employees,
and a program for early return to work and cooperative efforts by the
employees, the employer, and the managed care plan to promote workplace health
and safety consultative and other services.
L. The managed care plan must describe a
procedure or program through which participating health care providers may
obtain information on the following topics:
(1) treatment parameters adopted by the
commissioner;
(2) maximum medical
improvement;
(3) permanent partial
disability rating;
(4) return to
work and disability management;
(5)
health care provider obligations in the workers' compensation system;
and
(6) other topics the managed
care plan deems necessary to obtain cost-effective medical treatment and
appropriate return to work for an injured employee.
The medical director or a designee must document attendance for
a minimum of 12 hours of education during the first year, and four hours each
year thereafter, covering any of the topics listed in subitems (1) to (6). The
documentation shall be submitted to the commissioner upon request. The medical
director or designee must be available as a consultant on these topics to any
health care provider delivering services under the managed care plan.
M. The managed care
plan must specify any medical treatment standards it has developed for medical
services that have not already been prescribed by the commissioner and that are
reasonably likely to be used in the treatment of workers' compensation
injuries. The managed care plan shall make the standards available for review
by the commissioner upon request. All managed care plan health care providers
and those providing services under part
5218.0500 shall be governed by
these treatment standards and by the standards adopted by the commissioner
under Minnesota Statutes, section
176.83, subdivision 5. A
managed care plan may not prescribe treatment standards that disallow, in all
cases, treatment that is permitted by the commissioner's standards. However,
this item does not require ongoing treatment in individual cases if the
treatment is not medically necessary, even though the maximum amount of
treatment permitted under any standard has not been given.
N. The managed care plan must provide other
information as the commissioner considers necessary to determine compliance
with this chapter.
Subp.
2.
Notification; approval or denial.
Within 30 days of receipt of an application the commissioner
must notify an applicant for certification of any additional information
required or modification that must be made. The commissioner must notify the
applicant in writing of the approval or denial of certification within 30 days
of receipt of the additional information or modification. If the certification
is denied, the applicant must be provided, in writing, with the reason for the
denial.
Subp. 3.
Review of decision.
Any person aggrieved by a denial of certification by the
commissioner may request in writing, within 30 days of the date the denial is
served and filed, the initiation of a contested case proceeding under Minnesota
Statutes, chapter 14. Following receipt of the administrative law judge's
findings and recommendations, the commissioner shall issue a final decision in
accordance with Minnesota Statutes, section
14.62. An
appeal from the commissioner's final decision and order may be taken to the
workers' compensation court of appeals pursuant to Minnesota Statutes, sections
176.421
and
176.442.
