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 under that section by providing a managed care program which has been approved by the commissioner. A managed care program shall not be approved unless the commissioner finds that:
(a)The network or panel of health care providers is sufficiently comprehensive with respect to both geography and medical specialties, including reasonable access to treatment for injuries or personal injuries.
(b)The program provides for treatment and aids outside of the network or panel, if the necessary services or aids cannot be provided within the network or panel, or if emergency circumstances prohibit use of t
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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 under that section by providing a managed care program which has been approved by the commissioner. A managed care program shall not be approved unless the commissioner finds that:
(a) The network or panel of health care providers is sufficiently comprehensive with respect to both geography and medical specialties, including reasonable access to treatment for injuries or personal injuries.
(b) The program provides for treatment and aids outside of the network or panel, if the necessary services or aids cannot be provided within the network or panel, or if emergency circumstances prohibit use of the network or panel, or in such other circumstances as the commissioner may find.
(c) The program includes a process for determining professional qualifications of health care providers in the network or panel.
(d) The program provides for acceptable quality assurance measures.
(e) The program includes both inpatient and outpatient case management and rehabilitation case management.
(f) The program provides an employee with reasonable access to a second medical opinion, inside or outside the program, regarding diagnosis or the proper course of treatment, and adequate methods for resolving conflicting medical opinion.
(g) The program maintains a business office in New Hampshire for its staff of resident injury management facilitators, case managers, and rehabilitation managers.
II. No managed care program shall limit the right to a hearing under RSA 281-A:43, I, shall require as a condition of employment that any person engage in any practice or conduct outside of the course of employment, except in connection with and as part of treatment for an injury, or shall vary the methods for calculating weekly payments for disability compensation under RSA 281-A:28 or 281-A:31 or for calculating scheduled permanent impairment awards under RSA 281-A:32.
III. In addition to approval by the commissioner as required under paragraph I, and except for approvals within the residual market made before June 30, 1995, approval of a managed care program shall require an affirmative vote of ratification of such approval by the advisory council on workers' compensation, established under RSA 281-A:62.
IV. A managed care program shall be deemed to have been approved by the commissioner unless, within 45 days after its filing with the commissioner, the commissioner makes a preliminary determination of noncompliance, specifying in writing the reasons why the program does not appear to conform to the requirements of paragraph I. The proponent of such program shall have the right to a hearing before the commissioner to contest the preliminary determination. A managed care program approved or deemed approved by the commissioner shall be submitted to the advisory council within 5 days of such approval or deemed approval and shall be deemed to have been ratified by the advisory council unless, at its first regularly-scheduled meeting held at least 19 days after approval or deemed approval by the commissioner, the council, by a majority vote of all its members qualified to vote on ratification, declines to ratify the plan, specifying in writing the reasons why the program does not appear to conform to the requirements of paragraph I. The proponent of such program shall have the right to a hearing before the council to contest the council's declination. Neither the commissioner nor the insurance commissioner shall be qualified to vote on ratification.
V. Every managed care program shall include a sufficient number of injury management facilitators, including resident injury management facilitators, who shall be qualified by reason of education, training, and experience to manage the injured employee's medical, hospital and remedial care, vocational rehabilitation, modified duty, and return to work plans. An injury management facilitator shall work with the injured employee, employer, and medical, hospital and other providers to ensure that the injured employee receives effective, timely, and appropriate services in order to achieve maximum medical improvement and an expeditious return to work. Any person employed as an injury management facilitator by a managed care program or operating as an injury management facilitator in conjunction with a managed care program under this section shall be approved by the commissioner with ratification by the workers' compensation advisory council. The commissioner shall, in consultation with the advisory council, by rule determine the number of facilitators which shall be sufficient.
VI. (a) The commissioner shall monitor approved managed care programs and shall review the effectiveness of the various programs, cost savings achieved by such programs, and the appropriateness and timeliness of services delivered to the injured employee by such programs. The commissioner shall review each managed care program for purposes of determining the program's continued compliance with the standards for approval and delivery of service. Such review shall take place prior to the expiration of 3 years from the date the program's approval was ratified by the advisory council. Additional review shall take place at least once every 5 years thereafter, or whenever the commissioner determines that such review is required to ensure the program is in compliance with this section. Upon such review, if the commissioner determines after a hearing that a managed care program has failed to maintain compliance with the standards for approval, the commissioner shall withdraw approval of the plan and immediately notify the chairperson of the advisory council of such withdrawal. The commissioner's decision to withdraw approval of a managed care program shall be submitted to the advisory council within 5 days of such a decision and shall be deemed accepted by the advisory council unless, at its first regularly scheduled meeting held at least 19 days after the commissioner's decision, the council, by a majority vote of all its members qualified to vote on ratification, declines to ratify the decision, stating in writing the reasons why the program continues to comply with the requirements of this section and rules adopted pursuant to it. Neither the commissioner nor the insurance commissioner shall be qualified to vote on ratification.
(b) If the commissioner determines that a managed care program has failed to comply with the provisions of this section or the rules adopted to implement such section, but that such failure does not warrant withdrawal of approval of the program, the commissioner may, after notice to the managed care program and hearing, assess a civil penalty of not more than $100 for each such failure, which shall be deposited into the department of labor restricted fund established in RSA 273:1-b. If a managed care program fails to pay such penalty, the commissioner shall recover the penalty in a civil action in the superior court of the county of jurisdiction.
(c) The commissioner, with the approval of the workers' compensation advisory council and the governor and council, may enter into such contracts as may be necessary to analyze and study the effectiveness of managed care programs. The cost of any contracts entered into under this subparagraph shall be a charge against the workers' compensation administration fund, established under RSA 281-A:59.