SB 6393 - DIGEST

Provides that, subject to the terms and limitations specified in this act, a self-insured employer may furnish to its workers, or the department may furnish to some or all workers covered by the state fund, solely through workers' compensation managed care arrangements such proper and necessary medical, surgical, and hospital care and services for the period of a worker's disability from a covered injury as may be required under chapter 51.36 RCW, and which must be provided in accordance with practice parameters and protocols established under this chapter.

Provides that, before a self-insured employer may be authorized to offer or use a workers' compensation managed care arrangement in this state, the self-insurer's managed care plan of operation must be approved by the department.

Requires a self-insured employer or the department, as the case may be, to make full and fair disclosure in writing of the provisions, restrictions, and limitations of the workers' compensation managed care arrangement to affected workers, including at least: (1) A description, including address and telephone number, of the network providers, including primary care physicians, specialty physicians, hospitals, and other health care providers;

(2) A description of the coverage for emergency and urgently needed care provided within and outside the service area;

(3) A description of limitations on referrals; and

(4) A description of the grievance process.

Requires a workers' compensation managed care arrangement to have and use procedures for hearing complaints and resolving written grievances from injured workers and health care providers. The procedures must be aimed at mutual agreement for settlement and may include arbitration procedures.

Authorizes the director to suspend the authority of a self-insurer to offer a workers' compensation managed care arrangement or may order compliance within sixty days, if the director finds that: (1) The self-insurer or its managed care contractor is in substantial violation of its contracts;

(2) The self-insurer or its managed care contractor is unable to fulfill its obligations under outstanding managed care arrangement contracts;

(3) The self-insurer or managed care contractor knowingly uses a provider who is furnishing or has furnished health care services without having an existing license or other authority to practice or furnish health care services in this state;

(4) The self-insurer no longer meets the requirements for authorization as originally issued; or

(5) The self-insurer has violated any provision of this act or rule or order of the director adopted under this act.