HB 255-FN – AS INTRODUCED
2013 SESSION
01/09
HOUSE BILL 255-FN
AN ACT relative to the workers’ compensation law.
SPONSORS: Rep. Daniels, Hills 40
COMMITTEE: Labor, Industrial and Rehabilitative Services
This bill makes certain changes in the law relative to workers’ compensation including:
I. Allowing an employer or the employer’s insurance carrier or self-insurer to select a health care provider during the first 10 days of an employee’s injury.
II. Requiring pharmacies to substitute generic drugs unless the prescribing physician indicates that the brand name drug is medically necessary.
III. Establishing a 3-year pilot program in certain counties for a 90-day preferred provider network.
IV. Allowing an employer or employer’s insurance carrier or self-insurer to provide a pharmacy benefits management program.
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Explanation: Matter added to current law appears in bold italics.
Matter removed from current law appears [in brackets and struckthrough.]
Matter which is either (a) all new or (b) repealed and reenacted appears in regular type.
13-0193
01/09
STATE OF NEW HAMPSHIRE
In the Year of Our Lord Two Thousand Thirteen
AN ACT relative to the workers’ compensation law.
Be it Enacted by the Senate and House of Representatives in General Court convened:
1 New Paragraph; Workers’ Compensation; Medical, Hospital, and Remedial Care. Amend RSA?281-A:23 by inserting after paragraph VI the following new paragraph:
VII. Pharmacies, including mail-order pharmacies, shall substitute generically equivalent drug products for all legend and non-legend prescriptions unless the prescribing practitioner handwrites “medically necessary” on each paper prescription, uses electronic indications when transmitted electronically, or gives instructions when transmitted orally that the brand name drug product is medically necessary.
2 New Sections; Workers’ Compensation; Employer Selection of Health Care Provider During First 10 Days; 90-Day Employer Preferred Provider Network; Pharmacy Benefits Management Programs. Amend RSA 281-A by inserting after section 23-b the following new sections:
281-A:23-c Employer Selection of Health Care Provider During First 10 Days. During the first 10 days following the employee’s notice to the employer of an injury with the intention to seek medical care, an employer, employer’s insurance carrier, or self-insurer that is subject to the provisions of this chapter may satisfy the requirements and provisions of RSA 281-A:23 and the employee’s rights under that section by selecting a health care provider to treat the employee during those first 10 days.
281-A:23-d 90-Day Employer Preferred Provider Network.
I. There is established a 3-year pilot program for a 90-day employer preferred provider network in the counties of Hillsborough, Rockingham, and Merrimack beginning on the effective date of this section.
II.(a) During the first 90 days following the employee’s notice to the employer of an injury with the intention to seek medical care, an employer, employer’s insurance carrier or self-insurer that is subject to the provisions of this chapter may satisfy the requirements and provisions of RSA 281-A:23 and the employee’s rights under that section by providing a preferred provider network (hereafter “network”) which has been approved by the commissioner, within which the employee shall obtain medical, surgical, and hospital services, remedial care, and nursing that the network provides.
(b) The employer, employer’s insurance carrier, or self-insurer shall educate and inform the injured employee about the employee’s rights and obligations while receiving treatment in the network, including the employee’s right to resolution of medical disputes.
III. A network shall not be utilized by an employer unless the employer’s use of the preferred provider network has been approved as specified in this section. A network shall not be approved unless the commissioner finds that:
(a) The network includes providers who have experience and expertise in treating work-related injuries.
(b) The network of health care providers is sufficiently comprehensive with respect to geography based on the employer’s worksite or worksites, and has a minimum of 2 health care providers in each medical specialty included in the network.
(c) The program shall include a process for determining professional qualifications of health care providers in the network. Internal credentialing procedures shall be sufficient, if the data utilized in the process of credentialing is in enough detail to enable the commissioner to verify the validity of the process.
(d) The network provides for acceptable quality assurance measures.
IV.(a) The employee shall have the right to treatment and medical aids outside of the network:
(1) If necessary treatment or medical aids cannot be provided within the network.
(2) If emergency circumstances prohibit use of the network.
(3) If an injured employee has been treated within the prior 6 months for a prior recurrence or aggravation of the work injury by a provider who is not a member of the network, if such provider complies with all the terms, conditions, protocols, referral procedures, and levels of reimbursement established by the network.
(4) If the injured employee’s residence is located more than 60 miles of travel from the nearest relevant medical care provider in the network.
(5) In such other circumstances as the commissioner may find.
(b) The employee shall have reasonable access to a second medical opinion, inside or outside the network, regarding diagnosis or the proper course of treatment, and adequate methods for resolving conflicting medical opinion.
(c) If the employee is dissatisfied with a determination made by a health care provider within the network relating to compensability, degree of disability, or degree of impairment arising from an injury, the employee may apply to the commissioner for authorization to obtain an independent examination, pursuant to RSA 281-A:38-a.
V. In addition to approval by the commissioner as required under paragraph II, approval of a network shall require an affirmative vote of ratification of such approval by the advisory council on workers’ compensation, established under RSA 281-A:62, using the same time limits as for approval of managed care programs under RSA 281-A:23-a.
VI. The approval of a network shall expire after 3 years, but may be offered for approval again at any time, before or after such expiration. Notice of any change in the providers within, or adding a medical specialty to, an approved network shall be sent to the commissioner within 10 days of such change. The commissioner shall have the power to revoke approval of a network if at any time it fails to meet the requirements of paragraph II.
VII. The commissioner shall adopt rules, under RSA 541-A, relative to the approval and operation of networks.
VIII. The advisory council on workers’ compensation shall review the effectiveness of the networks and issue a report recommending its continuation, expansion, or conclusion within 3 years of the effective date of this section. The report shall be submitted to the president of the senate, the speaker of the house of representatives, the governor, the commissioner of labor, and the insurance commissioner.
281-A:23-e Pharmacy Benefits Management Programs.
I. An employer, employer’s insurance carrier, or self-insurer that is subject to the provisions of this chapter may satisfy the requirements and provisions of RSA 281-A:23 and the employee’s rights to medicine under that section by providing a pharmacy benefits management program which has been approved by the commissioner.
II. A pharmacy benefits management program shall not be approved unless the commissioner finds that:
(a) The program provides for educating the injured employee about the proper use of the network to obtain medicines.
(b) The program is sufficiently comprehensive with respect to geography, and has live assistance available by phone and the Internet at all times.
(c) The program allows the injured employee to obtain medicines outside the program if the necessary medicine cannot be provided within the program, or if emergency circumstances prohibit the use of the program, or in such other circumstances as the commissioner may find.
(d) The program includes a process for determining professional qualifications of pharmacies in the program.
(e) The program provides for acceptable quality assurance measures.
(f) The program is accredited by the Utilization Review Accreditation Committee (URAC) organization or an equivalent organization.
(g) The program does not require the injured worker to obtain medicines by mail, except at the employee’s option.
(h) The program provides that a first fill of medicine prescribed at initial treatment made through the program is at no cost to the injured employee.
III. In addition to approval by the commissioner as required under paragraph II, approval of a pharmacy benefits management program shall require an affirmative vote of ratification of such approval by the advisory council on workers’ compensation, established under RSA 281-A:62, in the same manner as approval of managed care programs under RSA 281-A:23-a. Such approval shall expire in 5 years and be subject to re-approval.
IV. Every pharmacy benefits management program shall be subject to the same oversight and review by the commissioner as managed care programs under RSA 281-A:23-a.
3 Workers’ Compensation; Payment for Reasonable Value of Services. Amend RSA 281-A:24, I to read as follows:
I. [The employer or the employer’s insurance carrier shall pay the full amount of the health care provider’s bill unless the employer or employer’s insurance carrier can show just cause as to why the total amount should not be paid.] In the absence of any contract setting reimbursement rates, the employer or the employer’s insurance carrier shall pay the physician, surgeon, or medical facility a reasonable fee for services and reimbursement for necessary services. The employer or its insurance carrier shall have the burden to show what amount is reasonable in the event of a dispute. Effort shall be made to resolve any dispute as to the reasonable value of service prior to applying to the commissioner for resolution of such a dispute. Whenever an injured employee receives medical and hospital service or other remedial care under the provisions of this chapter and a dispute arises between the employer and the person, firm, or corporation rendering such service or care as to the reasonable value of the service or care, the commissioner shall have exclusive jurisdiction to determine the reasonable value of such service or care. Following the commissioner’s determination, any interested party may petition for a hearing and all interested parties shall be entitled to notice and hearing if it is determined that all reasonable efforts to resolve the dispute have failed. The commissioner or the commissioner’s authorized representative shall make a finding as to the reasonable value of such services or care rendered, and such findings shall be final.
4 Effective Date. This act shall take effect January 1, 2014.
LBAO
13-0193
01/14/13
HB 255-FN - FISCAL NOTE
AN ACT relative to the workers’ compensation law.
FISCAL IMPACT:
The Department of Labor states this bill, as introduced, may decrease state, county and local expenditures by an indeterminable amount if FY 2014 and each year thereafter. There is no fiscal impact on state, county or local revenues.
METHODOLOGY:
The Department of Labor states this bill makes changes to the workers’ compensation law by allowing an employer or the employer’s insurance carrier or self-insurer to select a health care provider during the first 10 days of an employee’s injury, requires pharmacies to substitute generic drugs unless the prescribing physician indicates the brand name is medically necessary, allows an employer or the employer’s insurance carrier or self-insurer to provide a pharmacy benefits management program, and establishes a 3-year pilot program for a 90-day preferred provider. The Department assumes this bill will result in savings related to the payouts of medical benefits under worker’s compensation but is not able to determine the amount of any savings. As a result state, county, and local expenditures may decrease by an indeterminable amount.