Minnesota Administrative Rules

5218.0200 COVERAGE RESPONSIBILITY OF MANAGED CARE PLAN.

Subpart 1.

Scope.

A managed care plan shall provide comprehensive medical services according to its certification and Minnesota Statutes, chapter 176, and all other applicable statutes and rules.

Subp. 2.

Contracts and coverage.

A managed care plan must contract with the insurer liable for coverage of employees with a personal injury under Minnesota Statutes, chapter 176. Contracts with the insurer must include the provisions required by part 5218.0300, subpart 1, and are subject to the conditions of coverage in subparts 3 to 6.

Subp. 3.

Multiple plans.

Insurers may contract with multiple managed care plans to provide coverage for employers. When an insurer contracts with multiple managed care plans to cover the same employer, each employee shall have the initial choice within a reasonable time designated by the employer and insurer to select the managed care plan that will manage the employee's care. The employee must select a managed care plan from those that have a contract with the insurer liable for the personal injury under Minnesota Statutes, chapter 176, and that provide services within the mileage restrictions under part 5218.0100, subpart 1, item F, subitem (7).

Subp. 4.

Restrictions on employer or insurer formed plans.

Any person or entity, other than a workers' compensation insurer licensed under Minnesota Statutes, chapter 79A, or an employer for its own employees, may apply for certification as a certified managed care plan. A self-insured employer, an entity licensed under Minnesota Statutes, chapter 62C or 62D, or a preferred provider organization that is subject to Minnesota Statutes, chapter 72A, is eligible for certification. An employee of a certified managed care plan shall not be required to obtain services under the plan.

This subpart does not restrict cooperative efforts, whether by contract or otherwise, between a managed care plan, employer, third party administrator, and insurer to accomplish the purposes of Minnesota Statutes, section 176.1351.

Subp. 5.

Coverage.

A.

An employee who gives notice to an employer of a compensable personal injury under Minnesota Statutes, chapter 176, on or after the effective date of the managed care plan contract with the insurer liable for the injury under Minnesota Statutes, chapter 176, shall receive medical services in the manner prescribed by the terms and conditions of the managed care plan contract. An employee may not be required to receive medical services under the managed care plan until the notice required by part 5218.0250 is given to the employee.

B.

If the employer received notice of the injury before the effective date of the managed care plan contract, the employee may continue to treat with a nonparticipating provider who has been treating the injury until the employee requests a change of doctor. At that time, further services shall be provided by the managed care plan according to part 5218.0100, subpart 1, item F, subitems (2) and (3). Services by health care providers who are not participating providers must be delivered according to part 5218.0500.

C.

Except as provided in part 5218.0500, an employer may elect to require an employee who has notified the employer of a claimed workers' compensation injury to receive treatment from a certified managed care plan before the employer accepts or denies liability for the injury. In such cases, the employer is liable for the cost of any treatment related to the claimed personal injury that is given by a participating health care provider before notice is given to the employee of a denial of liability, even if the employer is later determined to be not liable for the claimed injury. If liability is denied, the employer cannot pursue reimbursement from the employee. This item does not limit the employer's right to pursue any other applicable subrogation or reimbursement rights it may have against another entity.

D.

The employee may receive treatment from any health care provider chosen by the employee after a notice of denial of liability has been given to the employee, or if the employer, after notice of a claimed injury, does not require the employee to receive treatment from a managed care plan prior to accepting liability for a claimed injury. If the employer later accepts liability or is determined by the commissioner, a compensation judge, or an appellate court to be liable for the claimed injury, the employer is responsible for the cost of all reasonable and necessary medical treatment received by the employee from the health care provider. If the employer admits liability for the claimed injury within 14 days after receiving notice of the injury, the employer may require that further medical treatment be received through the managed care plan unless the employee had a documented history of treatment with the health care provider as described in part 5218.0500, before the injury. If liability is admitted or determined later than 14 days after notice of the injury and the employee has been receiving treatment from a nonparticipating provider under this item, the employee is not required to receive further treatment under the managed care plan, if the health care provider agrees to comply with part 5218.0500, subpart 2.

Subp. 6.

Termination of coverage.

To ensure continuity of care, the managed care plan contract shall specify the manner in which an injured employee with a compensable injury will receive medical services when a managed care plan contract or a contract with a health care provider terminates. When a contract with a health care provider terminates, or when managed care plan coverage for an injured employee is being transferred from one managed care plan to another, the employee may continue to treat with the health care provider under the terminated contract until the employee requests a change of doctor. At that time further services shall be provided under the managed care plan in accordance with the procedures in part 5218.0100, subpart 1, item D, subitem (3), units (b) and (c). Services by providers who are not participating providers must be performed according to part 5218.0500.

Statutory Authority:

MS s 176.1351

History:

18 SR 1379

Published Electronically:

June 11, 2008