Rule 54: Managed Care — Coverage

A. Contracts.

1. In order to provide management of treatment for injuries and diseases compensable under the Nebraska Workers’ Compensation Act a managed care plan must contract with:

a. an insurer licensed by the Nebraska Department of Insurance to write workers’ compensation insurance in this state that has issued a current workers’ compensation insurance policy or policies; or

b. a risk management pool formed pursuant to the Intergovernmental Risk Management Act that provides group self-insurance to member employers; or

c. an individual employer approved for self-insurance by the court.

2. All contracts pursuant to Rule 54,A,1 shall specify the billing and payment procedures that will be utilized, and how the aggressive case management, early return to work, and cooperative efforts to promote workplace health and safety consultative services will be provided. 

3. All contracts pursuant to Rule 54,A,1 shall specify that any contractual obligations of an insurer, risk management pool, or self-insured employer to allow a managed care plan to provide medical, surgical, or hospital services for employees pursuant to the Nebraska Workers’ Compensation Act shall be null and void upon revocation of the certification of the managed care plan.

4. Once compensability has been accepted or determined, the employer may require that employees subject to the contract shall receive medical, surgical, and hospital services in the manner prescribed in the contract.

5. The employer shall remain liable for any health care services required under the Nebraska Workers’ Compensation Act that the managed care plan does not provide.

B. Multiple Plans. An insurer, risk management pool, or self-insured employer may contract with multiple managed care plans to provide coverage for employers. When an insurer, risk management pool, or self-insured employer contracts with multiple managed care plans to provide coverage for the same employer, and more than one such plan has participating physicians within the mileage restrictions established pursuant to Rule 53,E,7 whose scope of practice is appropriate for treatment of the injury in question, the employee shall have the right to select the managed care plan that will manage the employee’s care; except that if any such certified managed care plan also provides group health insurance for the employer and the employee is obligated to receive services under the group health insurance plan, then that plan, if the employer so elects, shall also manage the employee’s care for workers’ compensation purposes.

C. Coverage. 

1. If an employee gives notice of injury to an employer under the Nebraska Workers’ Compensation Act on or after the effective date of the managed care plan contract with the insurer, risk management pool, or self-insured employer, and if compensability has been accepted or determined, then the employee may be required to receive services under the managed care plan; except that an employee may not be required to receive services under the managed care plan until the notice required by Rule 55 has been given to the employee. 

2. If the employer received notice of the injury before the effective date of the managed care plan contract, the employee may not be required to receive services under the managed care plan until the employee requests a change of physician. At that time the employee may be required to receive further services under the managed care plan. 

3. Prior to acceptance or determination of compensability, or subsequent to the denial of compensability, the employee may not be required to receive services under a managed care plan.

4. If compensability is denied by the insurer, risk management pool, or self-insured employer, the employee may leave the managed care plan and the employer shall be liable for medical, surgical, and hospital services previously provided.

D. Termination of Coverage. 

1. To ensure continuity of care, the managed care plan contract shall specify the manner in which an employee will receive health care services when a managed care plan contract or a contract with a health care provider terminates.

2. When a contract with a participating primary treating physician terminates, the employee may continue to treat with such physician if the physician remains in good standing in Nebraska or the state in which he or she practices, and if the physician agrees to refer the employee to the managed care plan for any other treatment that the employee may require with respect to the injury in question, and if the physician agrees to comply with all of the rules, terms, and conditions of the managed care plan with respect to treatment of the injury in question. 

3. When managed care plan coverage for an employee is transferred from one managed care plan to another, the employee may continue to treat with the primary treating physician selected under the old plan if such physician agrees to refer the employee to the new managed care plan for any other treatment that the employee may require with respect to the injury in question, and if the physician agrees to comply with all of the rules, terms, and conditions of the new managed care plan with respect to treatment of the injury in question. If the employee requests a change in the primary treating physician, further services will be provided under the new managed care plan.