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The latest legislative and regulatory activity that impacts you and the services we provide

Policy Matters Brief - February 7, 2024

February 7, 2024 · Public Policy & Regulatory Affairs Team

Arizona looks to expand PTSD coverage

A bill recently filed in the Arizona State Legislature would expand the current post-traumatic stress disorder presumption coverage to now include 911 dispatchers. HB 2492 would modify the current PTSD presumption language to clarify who qualifies for benefits. The bill extends coverage from “policemen” to “peace officers” and “public safety telecommunicators”. It also expands the list of qualifying events or conditions to include “using deadly force” and “witnessing death of another public safety employee.” To read the bill, click here.

California workers’ comp drug formulary updated

The California Division of Workers’ Compensation (DWC) issued an order updating its Medical Treatment Utilization Schedule (MTUS) Drug List (the drug formulary), effective February 15. The order adopts the MTUS Drug List v.11, which includes changes based on the American College of Occupational and Environmental Medicine (ACOEM) Practice Guidelines, including new and revised treatment recommendations based on updates to the ACOEM Shoulder Disorders Guideline and the COVID-19 Guideline. More details on this update (and a record of past updates) can be viewed on the DWC formulary orders webpage. California state regulations permit the DWC to update the MTUS Drug List on a quarterly or more frequent basis.

New Jersey first responder cardiovascular and cerebrovascular injury presumption law expanded; several other workers’ comp and auto bills introduced

New Jersey Assembly No. 5909, a bill expanding the state’s existing workers’ comp presumptive coverage law for cardiovascular or cerebrovascular injury or death of a first responder, was recently signed into law. The bill went into effect on January 16, 2024 and applies to “all applicable injuries and deaths pending on the date of enactment.” It added any career emergency medical technician or paramedic engaged in public emergency medical and rescue services to the list of eligible personnel. This presumption applies to paid, part-paid, or volunteer firefighters, members of a volunteer first aid or rescue squad, or career emergency medical technicians or paramedics, responding to an applicable law enforcement, public safety, or medical emergency. It is worth noting that the law was amended to state that the presumption is rebuttable by use of causal factors like horseplay, skylarking, self-infliction, voluntary intoxication, and illicit drug use.

Several other bills relating to workers’ comp and auto no-fault insurance coverage in New Jersey have also been introduced this year. The workers’ comp bills range from shortening the medical dispute timeframe to establishing a first responder COVID-19 supplemental benefits program in the Division of Workers' Compensation. Auto no-fault bills include: addressing fee schedules; increasing the required minimum PIP coverage; and repealing the compulsory no-fault law. One other recently introduced bill (Senate Bill 1943) would require both workers’ compensation and auto insurers to cover costs associated with a claimant’s medical use of cannabis. For more details on these bills and other pending legislation we are tracking in New Jersey, view our Legislative and Regulatory Tracker and select the insurance category you are interested in. The interactive map allows you to further narrow legislation down by state.

Indiana legislation would permit injured workers to choose their attending physician

Indiana House Bill 1246, introduced January 9, 2024, would (if passed and signed into law) amend the state workers’ compensation law to permit injured workers to choose their attending physicians. Under the bill, employers would still be allowed to choose the physician if the injury renders the injured worker unable to make a decision or in cases where immediate medical attention is required. Similar attempts at changing the law to give injured workers this choice have been made in prior years but have failed thus far. It is worth noting that February 5 was the last scheduled day for the 3rd reading of House bills in the House of Representatives, and HB 1246 did not meet that deadline. The bill was referred to the House Employment, Labor and Pensions Committee after introduction but with no subsequent formal action.

Tennessee legislation would permit injured workers to choose their treating physician

Tennessee General Assembly House of Representatives HB 1467 proposes changes to existing claims and payment instructions, which would permit injured workers to choose a treating physician in any specialty and includes other changes related to that selection. This would amend existing language that requires employers to designate three or more independent reputable physicians, surgeons, chiropractors, or specialty practice groups. We will continue to follow and advise of any movement on this bill, which was originally introduced in January 2023.

Wisconsin bills would add workers’ comp presumptive coverage for an injury from an employer-required vaccine

Wisconsin Senate Bill 923, introduced January 19, would (if passed and signed into law) provide that an injury caused to an employee by a vaccine the employee was required by or coerced by their employer to receive is presumed to be caused by the individual's employment for workers’ compensation purposes. Such a presumption would require a diagnosis and may be rebutted by specific evidence that the injury was caused outside of employment. SB 923 is similar to another pending bill in the Wisconsin Assembly, Assembly Bill 613, introduced in late October of last year.

Virginia workers’ comp bill would place time limits on provider medical payment disputes and payer recovery of medical payments for older dates of service

Virginia House Bill 205 would (if passed and signed into law) amend the state workers’ comp law to remove a provision that only applies a one-year time limit to a health care provider’s ability to dispute a medical bill payment with the Workers’ Compensation Commission (WCC) for services rendered after July 1, 2014. The bill would also remove a similar provision that only applies a one-year time limit to an employer or insurer’s recovery of a payment made to a provider for services rendered after July 1, 2014. The effect would be to enforce the same one-year time limits regardless of the date of service. Some have viewed the current law’s exemptions for those older dates of service as a loophole. HB 205 was formally introduced on January 10, 2024 and passed the House of Delegates on January 29. The bill is currently pending in the Senate.

Colorado DWC schedules annual stakeholder meetings to review potential updates to medical rules

The Colorado Division of Workers’ Compensation (DWC) announced its 11th annual series of stakeholder meetings to learn about workers’ compensation issues and consider revisions to its rules governing the medical fee schedule and utilization guidelines. Beginning in March of 2024, the DWC will hold three monthly virtual meetings on the following dates:

March 28 – medical review requirements for prior authorization appeals and reviewing gabapentin as a drug required to be obtained at a pharmacy, among several other topics
April 25 – a presentation by mid-level providers on their role in an injured worker’s claim, followed by discussion
May 23 – conversion factors and any other issues that may arise

Prior registration is required to attend. Stakeholders can register to attend here. The typical process for the DWC after these stakeholder meetings is to propose formal changes in the summer, approve and adopt the changes in the fall, and implement them on January 1 of the following year.

Ohio workers’ comp state fund drug formulary and first fill list updated

The Ohio Bureau of Workers’ Compensation (BWC) adopted updates to its outpatient medication formulary rule and first fill of outpatient medications rule appendices (both drug lists), effective February 1. The formulary was amended to modify the coverage restrictions for four medications:

Pregabalin – change the per-day limitation
Tiagabine – limiting reimbursement to claims in which the injured worker has an allowed condition of seizure disorder
Phenytoin and carbamazepine chew tabs – limiting reimbursement to claims with an allowed condition that results in an inability to swallow or absorb oral medications.

Also, the first fill list was amended to add Apixaban Tab Starter Pack 5 MG and Rivaroxaban Tab Starter Therapy Pack 15 MG & 20 MG with specific quantity limits.

Although the BWC uses its formulary and first fill list for state fund claims that it and its PBM administer, self-insuring employers are also permitted (but not required) to use them. The BWC formulary is intended to provide prescribers with a concise list of medications for treatment of approved conditions related to the claim, along with information regarding any restrictions or limitations on the use of an approved medication. The first fill list specifies the circumstances under which the BWC will reimburse for the first fill of prescription drugs for medical conditions identified for compensation or benefits before the BWC issues an initial claim determination order.

New Oklahoma legislation would exempt workers’ compensation insurance from conflicting PBM laws

Oklahoma Senate Bill 1567 and House Bill 3377 seek to exempt workers' compensation insurance from several conflicting requirements in current state law related to PBMs. Supported by the American Association of Payers, Administrators and Networks (AAPAN), both bills are designed to eliminate conflicting and duplicative regulation of workers' compensation PBMs that often require them to file information with the state that is not relevant for pharmacy care provided in the workers' comp insurance context. Existing law employs several concepts, such as patient cost-share and choice of pharmacy, which are not applicable concerns in the workers’ compensation setting in the state and have caused some confusion over the past few years.

Additional Optum resources:

For more information on these policy developments and others we have been tracking this year, be sure to visit our Legislative and Regulatory Tracker. Bills or regulations can be filtered by insurance line, topic, status and jurisdiction.

If you have questions on these or any other public policy developments, please contact our team at OptumWC.PolicyMatters@optum.com.

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