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Policy Matters Brief March 17, 2021

March 17, 2021 · Policy Matters team

California workers’ comp legislation would establish state-wide medical provider network

Workers’ compensation legislation introduced in California would (if passed and signed into law) establish a statewide medical provider network called the California Medical Provider Network (CAMPN). Injured workers could choose a provider from this network in lieu of their employer’s or insurer's medical provider network (MPN). If the employer or insurer has not established an MPN, the injured worker may choose to treat with a physician of their own choice or to treat with a physician in the CAMPN. An injured workers who is being treated by a CAMPN physician would be permitted to, at any time, change to a different treating physician within the CAMPN.

As introduced, AB 1465 states that the initial list of CAMPN physicians is to be created by including any physician who meets the prescribed criteria and is listed on any employer, insurer or private entity MPN on January 1, 2022 ‒ the date the CAMPN would be required to be implemented. The Division of Workers’ Compensation (DWC) would also be required , on or before that same date and after public hearings, to establish rules and procedures governing the CAMPN, including a continuity of care policy.

All treatment within the CAMPN would still need to be provided in accordance with the state’s adopted workers’ compensation medical treatment guidelines. Treatment would also still be subject to utilization review and independent medical review.

AB 1465 was introduced on February 19, 2021 and is separate from legislation introduced on February 3, AB 399, which would impose new requirements on MPNs and further limit the ability of payers and networks to negotiate contracted rates. An overview of AB 399 was provided in our last Policy Matters Brief.

Kentucky DWC proposes changes to UR and medical bill audit regulation

The Kentucky Department of Workers’ Claims (DWC) proposed changes to their regulation governing utilization review (UR) and medical bill audit, primarily to add a new DWC medical director position and amend the method by which UR appeals are handled. However, they are also proposing to split the regulation into sections that apply to UR and medical bill audit conducted before January 1, 2022 and others that apply to UR and bill audit conducted on or after January 1, 2022.

Under the proposed regulation, the new DWC medical director will be required to process appeals of UR and medical bill audit decisions rendered by insurers. The regulation proposes the DWC will charge a $400 fee for each appeal submitted to the medical director that is to be paid by the insurer. The process and related timeframes for these appeals are also outlined.

The DWC medical director’s other proposed responsibilities include:

  • At least annually, review and advise on the effectiveness of the medical fee schedule, treatment guidelines and pharmacy formulary in reducing costs and speeding the delivery of medical services to injured workers
  • Chair the state’s Workers’ Compensation Medical Advisory Committee to provide advice on issues related to the medical treatment of injured workers

The medical director will be required to be a Kentucky licensed physician in good standing with the Kentucky Board of Medical Licensure, and they may, when appropriate, seek the assistance of other physicians to assist or perform any tasks outlined within the regulation.

A public hearing on the proposed changes will be held on May 27, 2021, with written comments accepted until May 31. More information on this can be viewed here.

With auto no-fault fee schedules coming, Michigan DIFS announces first CPI adjustment

The Michigan Department of Insurance and Financial Services (DIFS) posted the first Consumer Price Index (CPI) medical component adjustment to be applied to the state’s upcoming auto no-fault fee schedules. This adjustment represents an increase of 4.11% for dates of service from July 2, 2021 through July 1, 2022 and only applies to services/products that are reimbursed based on the 2019 auto no-fault reform law’s provisions pertaining to services/products without an applicable Medicare rate.

The 2019 reform law based reimbursement for most services/products on specific markups above the applicable Medicare reimbursement rates. However, for those services/products without an applicable Medicare rate, the law states that reimbursement to providers is to be based on a percentage reduction of the amount payable for the treatment under the provider’s charge description master in effect January 1, 2019, or a percentage reduction of the average amount the provider charged for the treatment on January 1, 2019 – both adjusted annually based on change in the medical care component of the CPI.

As we noted in our last Policy Matters Brief, proposed rules providing further guidance on these fee schedules are currently pending. The proposed rule language includes requiring DIFS to post this CPI adjustment annually by March 1 via bulletin. A public hearing on the proposed rules is scheduled for March 26, 2021, with a written comment period also open until that date. More information on that rule-making can be viewed here.

New Hampshire Supreme Court rules in favor of medical marijuana for claimant

The New Hampshire Supreme Court recently ruled that the cost of medical marijuana treatments should be covered under the state workers’ compensation system in a specific claim. 

In the case, the claimant Panaggio suffered from chronic pain as a result of an accepted
work-related injury. Eventually, the claimant became an approved patient under the state’s medical marijuana program. After initial approval of the denial by the New Hampshire Compensation Appeals Board, the case was appealed. The court’s ruling held that the Controlled Substances Act does not criminalize the act of reimbursement for an employee’s purchase of medical marijuana and supported the claimant’s request for reimbursement from the carrier.  

New York adopts workers’ compensation DMEPOS fee schedule and authorization rules

As part of its ongoing modernization projects, the New York Workers’ Compensation Board, March 4, 2021, released final adopted rules related to a new Durable Medical Equipment, Prosthetics Orthotics and Supplies (DMEPOS) fee schedule and synergistic prior authorization requests (PAR) requirements. 

The newly adopted rules and fee schedule will transfer the existing DMEPOS fee schedule from the current state Medicaid rates to new state-specific workers’ compensation rates that are created and maintained by the WCB.  Additionally, the newly-adopted rules implement prior authorization requests (PAR) requirements for DMEPOS that will utilize the electronic web-based OnBoard system for handling and responding to submitted PARs. The new fee schedule and all PAR requirements will take effect June 7, 2021.

Virginia moves toward approving recreational marijuana

In early March 2021, the Virginia Legislature gave final approval to a bill that will legalize marijuana for adult recreational use. AB 2312 will also eliminate several criminal penalties for possession of up to one ounce of marijuana for those over age 21 and calls for establishing regulations to oversee the licensing, distribution and sale of recreational marijuana by approved entities. The bill, which would not permit the retail sale of marijuana for recreational purposes until 2024, has been sent to the Governor who has vocalized his support of the measure and is expected to sign the bill. 


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