70th OREGON LEGISLATIVE ASSEMBLY--1999 Regular Session
NOTE: Matter within { + braces and plus signs + } in an
amended section is new. Matter within { - braces and minus
signs - } is existing law to be omitted. New sections are within
{ + braces and plus signs + } .
LC 4227
Senate Bill 1322
Sponsored by Senator DERFLER
SUMMARY
The following summary is not prepared by the sponsors of the
measure and is not a part of the body thereof subject to
consideration by the Legislative Assembly. It is an editor's
brief statement of the essential features of the measure as
introduced.
Requires workers' compensation insurers and self-insured
employers to pay medical expenses incurred within 30 days from
date of filing of claim or through date claimant receives notice
of denial if claim is denied within 30 days of filing of claim.
A BILL FOR AN ACT
Relating to workers' compensation; creating new provisions; and
amending ORS 656.245.
Be It Enacted by the People of the State of Oregon:
SECTION 1. ORS 656.245 is amended to read:
656.245. (1)(a) For every compensable injury, the insurer or
the self-insured employer shall cause to be provided medical
services for conditions caused in material part by the injury for
such period as the nature of the injury or the process of the
recovery requires, subject to the limitations in ORS 656.225,
including such medical services as may be required after a
determination of permanent disability. In addition, for
consequential and combined conditions described in ORS 656.005
(7), the insurer or the self-insured employer shall cause to be
provided only those medical services directed to medical
conditions caused in major part by the injury.
(b) Compensable medical services shall include medical,
surgical, hospital, nursing, ambulances and other related
services, and drugs, medicine, crutches and prosthetic
appliances, braces and supports and where necessary, physical
restorative services. A pharmacist or dispensing physician shall
dispense generic drugs to the worker in accordance with ORS
689.515. The duty to provide such medical services continues for
the life of the worker.
(c) Notwithstanding any other provision of this chapter,
medical services after the worker's condition is medically
stationary are not compensable except for the following:
(A) Services provided to a worker who has been determined to be
permanently and totally disabled.
(B) Prescription medications.
(C) Services necessary to administer prescription medication or
monitor the administration of prescription medication.
(D) Prosthetic devices, braces and supports.
(E) Services necessary to monitor the status, replacement or
repair of prosthetic devices, braces and supports.
(F) Services provided pursuant to an accepted claim for
aggravation under ORS 656.273.
(G) Services provided pursuant to an order issued under ORS
656.278.
(H) Services that are necessary to diagnose the worker's
condition.
(I) Life-preserving modalities similar to insulin therapy,
dialysis and transfusions.
(J) With the approval of the insurer or self-insured employer,
palliative care that the worker's attending physician referred to
in ORS 656.005 (12)(b)(A) prescribes and that is necessary to
enable the worker to continue current employment or a vocational
training program. If the insurer or self-insured employer does
not approve, the attending physician or the worker may request
approval from the Director of the Department of Consumer and
Business Services for such treatment. The director may order a
medical review by a physician or panel of physicians pursuant to
ORS 656.327 (3) to aid in the review of such treatment. The
decision of the director is subject to the contested case and
review provisions of ORS 183.310 to 183.550.
(K) With the approval of the director, curative care arising
from a generally recognized, nonexperimental advance in medical
science since the worker's claim was closed that is highly likely
to improve the worker's condition and that is otherwise justified
by the circumstances of the claim. The decision of the director
is subject to the contested case and review provisions of ORS
183.310 to 183.550.
(L) Curative care provided to a worker to stabilize a temporary
and acute waxing and waning of symptoms of the worker's
condition.
(d) Except for services provided under a managed care contract,
out-of-pocket expense reimbursement to receive care from the
attending physician shall not exceed the amount required to seek
care from an appropriate attending physician of the same
specialty who is in a medical community geographically closer to
the worker's home. For the purposes of this paragraph, all
physicians within a metropolitan area are considered to be part
of the same medical community.
(2)(a) The worker may choose an attending doctor or physician
within the State of Oregon. The worker may choose the initial
attending physician and may subsequently change attending
physician two times without approval from the director. If the
worker thereafter selects another attending physician, the
insurer or self-insured employer may require the director's
approval of the selection and, if requested, the director shall
determine with the advice of one or more physicians, whether the
selection by the worker shall be approved. The decision of the
director is subject to a contested case review under ORS 183.310
to 183.550. The worker also may choose an attending doctor or
physician in another country or in any state or territory or
possession of the United States with the prior approval of the
insurer or self-insured employer.
(b) A medical service provider who is not a member of a managed
care organization is subject to the following provisions:
(A) A medical service provider who is not qualified to be an
attending physician may provide compensable medical service to an
injured worker for a period of 30 days from the date of injury or
occupational disease or for 12 visits, whichever first occurs,
without the authorization of an attending physician. Thereafter,
medical service provided to an injured worker without the written
authorization of an attending physician is not compensable.
(B) A medical service provider who is not an attending
physician cannot authorize the payment of temporary disability
compensation. Except as otherwise provided in this chapter, only
the attending physician at the time of claim closure may make
findings regarding the worker's impairment for the purpose of
evaluating the worker's disability.
(3) Notwithstanding any other provision of this chapter, the
director, by rule, upon the advice of the committee created by
ORS 656.794 and upon the advice of the professional licensing
boards of practitioners affected by the rule, may exclude from
compensability any medical treatment the director finds to be
unscientific, unproven, outmoded or experimental. The decision of
the director is subject to a contested case review under ORS
183.310 to 183.550.
(4) Notwithstanding subsection (2)(a) of this section, when a
self-insured employer or the insurer of an employer contracts
with a managed care organization certified pursuant to ORS
656.260 for medical services required by this chapter to be
provided to injured workers:
(a) Those workers who are subject to the contract shall receive
medical services in the manner prescribed in the contract.
Workers subject to the contract include those who are receiving
medical treatment for an accepted compensable injury or
occupational disease, regardless of the date of injury or
medically stationary status, on or after the effective date of
the contract. If the managed care organization determines that
the change in provider would be medically detrimental to the
worker, the worker shall not become subject to the contract until
the worker is found to be medically stationary, the worker
changes physicians or the managed care organization determines
that the change in provider is no longer medically detrimental,
whichever event first occurs. A worker becomes subject to the
contract upon the worker's receipt of actual notice of the
worker's enrollment in the managed care organization, or upon the
third day after the notice was sent by regular mail by the
insurer or self-insured employer, whichever event first occurs. A
worker shall not be subject to a contract after it expires or
terminates without renewal, except that workers with open claims
at the time of such expiration or termination shall remain
subject to the contract for that claim until closure. A worker
shall not be subject to a contract if the worker's primary
residence is more than 100 miles outside the managed care
organization's certified geographical area. Each such contract
must comply with the certification standards provided in ORS
656.260. However, a worker may receive immediate emergency
medical treatment that is compensable from a medical service
provider who is not a member of the managed care organization.
Insurers or self-insured employers who contract with a managed
care organization for medical services shall give notice to the
workers of eligible medical service providers and such other
information regarding the contract and manner of receiving
medical services as the director may prescribe. Notwithstanding
any provision of law or rule to the contrary, a worker of a
noncomplying employer is considered to be subject to a contract
between the State Accident Insurance Fund Corporation as a
processing agent or the assigned claims agent and a managed care
organization.
(b)(A) For initial or aggravation claims filed after June 7,
1995, the insurer or self-insured employer may require an injured
worker, on a case-by-case basis, immediately to receive medical
services from the managed care organization.
(B) If the insurer or self-insured employer gives notice that
the worker is required to receive treatment from the managed care
organization, the insurer or self-insured employer must guarantee
that any reasonable and necessary services so received, that are
not otherwise covered by health insurance, will be paid as
provided in ORS 656.248, even if the claim is denied, until the
worker receives actual notice of the denial or until three days
after the denial is mailed, whichever event first occurs. The
worker may elect to receive care from a primary care physician
who agrees to the conditions of ORS 656.260 (4)(g). However,
guarantee of payment is not required by the insurer or
self-insured employer if this election is made.
(C) If the insurer or self-insured employer does not give
notice that the worker is required to receive treatment from the
managed care organization, the insurer or self-insured employer
is under no obligation to pay for services received by the worker
unless the claim is later accepted.
(D) If the claim is denied, the worker may receive medical
services after the date of denial from sources other than the
managed care organization until the denial is reversed.
Reasonable and necessary medical services received from sources
other than the managed care organization after the date of claim
denial must be paid as provided in ORS 656.248 by the insurer or
self-insured employer if the claim is finally determined to be
compensable.
(5) Notwithstanding any other provision of this chapter, the
director, by rule, shall authorize nurse practitioners certified
by the Oregon State Board of Nursing and physician assistants
registered by the Board of Medical Examiners for the State of
Oregon who practice in areas served by Type A or Type B rural
hospitals described in ORS 442.470 to authorize the payment of
temporary disability compensation for injured workers for a
period not to exceed 30 days from the date of the first visit on
the claim. In addition, the director, by rule, may authorize such
practitioners and assistants who practice in areas served by a
Type C rural hospital described in ORS 442.470 to authorize such
payment.
(6) If a claim for medical services is disapproved for any
reason other than the formal denial of the compensability of the
underlying claim and this disapproval is disputed, the injured
worker, the insurer or self-insured employer shall request
administrative review by the director pursuant to this section,
ORS 656.260 or 656.327. The decision of the director is subject
to the contested case review provisions of ORS 183.310 to
183.550.
{ + (7) Notwithstanding any other provision of this chapter,
medical expenses incurred in the first 30 days from the date a
workers' compensation claim is filed shall be paid by the insurer
or self-insured employer. If the claim is denied within the first
30 days from the date a workers' compensation claim is filed, all
medical expenses incurred through the date the claimant receives
notice of the claim denial shall be paid by the insurer or
self-insured employer. + }
SECTION 2. ORS 656.245, as amended by section 25a, chapter 332,
Oregon Laws 1995, is amended to read:
656.245. (1)(a) For every compensable injury, the insurer or
the self-insured employer shall cause to be provided medical
services for conditions caused in material part by the injury for
such period as the nature of the injury or the process of the
recovery requires, subject to the limitations in ORS 656.225,
including such medical services as may be required after a
determination of permanent disability. In addition, for
consequential and combined conditions described in ORS 656.005
(7), the insurer or the self-insured employer shall cause to be
provided only those medical services directed to medical
conditions caused in major part by the injury.
(b) Compensable medical services shall include medical,
surgical, hospital, nursing, ambulances and other related
services, and drugs, medicine, crutches and prosthetic
appliances, braces and supports and where necessary, physical
restorative services. A pharmacist or dispensing physician shall
dispense generic drugs to the worker in accordance with ORS
689.515. The duty to provide such medical services continues for
the life of the worker.
(c) Notwithstanding any other provision of this chapter,
medical services after the worker's condition is medically
stationary are not compensable except for the following:
(A) Services provided to a worker who has been determined to be
permanently and totally disabled.
(B) Prescription medications.
(C) Services necessary to administer prescription medication or
monitor the administration of prescription medication.
(D) Prosthetic devices, braces and supports.
(E) Services necessary to monitor the status, replacement or
repair of prosthetic devices, braces and supports.
(F) Services provided pursuant to an accepted claim for
aggravation under ORS 656.273.
(G) Services provided pursuant to an order issued under ORS
656.278.
(H) Services that are necessary to diagnose the worker's
condition.
(I) Life-preserving modalities similar to insulin therapy,
dialysis and transfusions.
(J) With the approval of the insurer or self-insured employer,
palliative care that the worker's attending physician referred to
in ORS 656.005 (12)(b)(A) prescribes and that is necessary to
enable the worker to continue current employment or a vocational
training program. If the insurer or self-insured employer does
not approve, the attending physician or the worker may request
approval from the Director of the Department of Consumer and
Business Services for such treatment. The director may order a
medical review by a physician or panel of physicians pursuant to
ORS 656.327 (3) to aid in the review of such treatment. The
decision of the director is subject to the contested case and
review provisions of ORS 183.310 to 183.550.
(K) With the approval of the director, curative care arising
from a generally recognized, nonexperimental advance in medical
science since the worker's claim was closed that is highly likely
to improve the worker's condition and that is otherwise justified
by the circumstances of the claim. The decision of the director
is subject to the contested case and review provisions of ORS
183.310 to 183.550.
(L) Curative care provided to a worker to stabilize a temporary
and acute waxing and waning of symptoms of the worker's
condition.
(d) Except for services provided under a managed care contract,
out-of-pocket expense reimbursement to receive care from the
attending physician shall not exceed the amount required to seek
care from an appropriate attending physician of the same
specialty who is in a medical community geographically closer to
the worker's home. For the purposes of this paragraph, all
physicians within a metropolitan area are considered to be part
of the same medical community.
(2)(a) The worker may choose an attending doctor or physician
within the State of Oregon. The worker may choose the initial
attending physician and may subsequently change attending
physician two times without approval from the director. If the
worker thereafter selects another attending physician, the
insurer or self-insured employer may require the director's
approval of the selection and, if requested, the director shall
determine with the advice of one or more physicians, whether the
selection by the worker shall be approved. The decision of the
director is subject to a contested case review under ORS 183.310
to 183.550. The worker also may choose an attending doctor or
physician in another country or in any state or territory or
possession of the United States with the prior approval of the
insurer or self-insured employer.
(b) A medical service provider who is not a member of a managed
care organization is subject to the following provisions:
(A) A medical service provider who is not qualified to be an
attending physician may provide compensable medical service to an
injured worker for a period of 30 days from the date of injury or
occupational disease or for 12 visits, whichever first occurs,
without the authorization of an attending physician. Thereafter,
medical service provided to an injured worker without the written
authorization of an attending physician is not compensable.
(B) A medical service provider who is not an attending
physician cannot authorize the payment of temporary disability
compensation. Except as otherwise provided in this chapter, only
the attending physician at the time of claim closure may make
findings regarding the worker's impairment for the purpose of
evaluating the worker's disability.
(3) Notwithstanding any other provision of this chapter, the
director, by rule, upon the advice of the committee created by
ORS 656.794 and upon the advice of the professional licensing
boards of practitioners affected by the rule, may exclude from
compensability any medical treatment the director finds to be
unscientific, unproven, outmoded or experimental. The decision of
the director is subject to a contested case review under ORS
183.310 to 183.550.
(4) Notwithstanding subsection (2)(a) of this section, when a
self-insured employer or the insurer of an employer contracts
with a managed care organization certified pursuant to ORS
656.260 for medical services required by this chapter to be
provided to injured workers, those workers who are subject to the
contract shall receive medical services in the manner prescribed
in the contract. Each such contract must comply with the
certification standards provided in ORS 656.260. However, a
worker may receive immediate emergency medical treatment that is
compensable from a medical service provider who is not a member
of the managed care organization. Insurers or self-insured
employers who contract with a managed care organization for
medical services shall give notice to the workers of eligible
medical service providers and such other information regarding
the contract and manner of receiving medical services as the
director may prescribe.
(5) Notwithstanding any other provision of this chapter, the
director, by rule, shall authorize nurse practitioners certified
by the Oregon State Board of Nursing and physician assistants
registered by the Board of Medical Examiners for the State of
Oregon who practice in areas served by Type A or Type B rural
hospitals described in ORS 442.470 to authorize the payment of
temporary disability compensation for injured workers for a
period not to exceed 30 days from the date of the first visit on
the claim. In addition, the director, by rule, may authorize such
practitioners and assistants who practice in areas served by a
Type C rural hospital described in ORS 442.470 to authorize such
payment.
(6) If a claim for medical services is disapproved for any
reason other than the formal denial of the compensability of the
underlying claim and this disapproval is disputed, the injured
worker, the insurer or self-insured employer shall request
administrative review by the director pursuant to this section,
ORS 656.260 or 656.327. The decision of the director is subject
to the contested case review provisions of ORS 183.310 to
183.550.
{ + (7) Notwithstanding any other provision of this chapter,
medical expenses incurred in the first 30 days from the date a
workers' compensation claim is filed shall be paid by the insurer
or self-insured employer. If the claim is denied within the first
30 days from the date a workers' compensation claim is filed, all
medical expenses incurred through the date the claimant receives
notice of the claim denial shall be paid by the insurer or
self-insured employer. + }
SECTION 3. { + Nothing in the amendments to ORS 656.245 by
section 1 or 2 of this 1999 Act affects the operative or
applicability date provisions of sections 25a and 66, chapter
332, Oregon Laws 1995. + }
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