02-031 C.M.R. ch. 530
This Rule establishes procedural requirements governing the payment of medical and disability benefits by health, disability, and workers' compensation insurance companies so that injured workers whose workers' compensation claims have been controverted and who are awaiting Workers' Compensation Board determinations shall not incur any unnecessary financial burden.
This Rule is adopted by the Superintendent of Insurance, after consultation with the chair of the Workers' Compensation Board, pursuant to 39-A M.R.S.A. § 222(3) and 24-A M.R.S.A. § 212.
A. "Insured health plan" means any plan for the payment of medical or disability benefits for which payment or provision of services is secured under a medical or disability insurance policy, health maintenance organization contract, or similar product regulated by the Superintendent of Insurance.
B. "Health carrier" means the insurance company, nonprofit health service corporation, or other entity responsible for payment of benefits or provision of services under an insured health plan.
C. "Workers' compensation carrier" includes a self-insured employer.
A. If a workers' compensation claimant is awaiting a Board determination on a claim in which the employer or workers' compensation carrier has filed a notice of controversy contesting the work-relatedness of the claimant's condition, and the claimant is covered under an insured health plan, then the health carrier must determine eligibility and provide benefits to the claimant, according to the terms of the health plan but without regard to any policy exclusion for work-related injury or disease.
B. The health carrier may require the claimant to pursue the claim through the mediation level established pursuant to 39-A M.R.S.A. § 153(6) in order to preserve his or her entitlement to provisional payments. If the mediation results in an agreement that the condition is not work-related, or if there is no agreement and the claimant elects not to prosecute the workers' compensation claim further, the health carrier must either abide by
that decision or file a petition with the Board pursuant to 39-A M.R.S.A. § 305. The health carrier's liability for provisional benefit payments ceases if the Board determines that the claimant's condition is work-related, if the employer acknowledges for purposes of the Workers' Compensation Law that the claimant's condition is work-related, or if the employer or workers' compensation carrier makes or agrees to make any payment, to or for the benefit of the claimant, in settlement of the workers' compensation claim.
C. Unless a shorter period is provided for by law or by the terms of the health plan, any payments required by this Section shall be paid to or on behalf of the claimant within the following time limits. For periodic disability benefits, payment shall be made in full by the end of each 30-day period during which the claimant is entitled to benefits, subject to proof of loss. Other payments shall be made within 60 days after the health carrier receives proof of loss. Provided, however, that no payment is due until 10 days after the health carrier has received both:
(1) a request for provisional payment acknowledging the existence of a disputed workers' compensation claim; and
(2) proof that a notice of controversy has been filed.
D. Upon making any payment required by this Section, the health carrier shall notify the claimant that the payment is made on a provisional basis, pending resolution of the workers' compensation claim, and is subject to recovery or offset as provided in 39-A M.R.S.A. § 222(2). In particular, the health carrier shall clearly warn that the payment may be more than the amount the claimant is ultimately entitled to under the workers' compensation law, and that the claimant would then be liable to refund the difference.
A. The health carrier may exercise the right of offset at any time after receiving a request for payment pursuant to Section 4, by notifying the workers' compensation carrier in writing of the amount of provisional payment that has been or will be made and requesting reimbursement. A notice of offset is effective immediately upon receipt and remains in effect until expressly rescinded in writing.
B. If the health carrier is no longer liable for provisional payments, pursuant to Section 4, and a notice of offset is in effect, the workers' compensation carrier is obligated to reimburse the health carrier in such amounts and at such times as it would otherwise be obligated to pay the claimant, until the amount requested, reduced by any amount the health carrier has not yet paid or has already sought to recover directly from the claimant, has been paid in full.
C. If the workers' compensation carrier makes any payment directly to the claimant or health care provider within the meaning of 39-A M.R.S.A. § 206, rather than to the health carrier, while a notice of offset is in effect, the full amount of that payment shall be considered an obligation to the claimant for purposes of Subsection 5(B), and the appropriate reimbursement to the health carrier shall be due immediately from the workers' compensation carrier. Any resulting overpayment may be recovered from the claimant by the workers' compensation carrier once the health carrier has been paid.
D. If the health carrier accepts a claim and pays provisional benefits, the workers’ compensation carrier must treat the services as medically necessary and as rendered by an appropriate provider in compliance with all applicable procedural requirements. However, this Subsection does not exempt claimants or providers from compliance with notice requirements set forth in Subsection 206(9) and Section 208 of the Workers’ Compensation Act, Title 39-A M.R.S.A., or in rules adopted by the Workers’ Compensation Board, to the extent that such requirements by their terms are generally applicable to controverted claims.
If a self-funded employee benefit plan or a governmental benefit program, including but not limited to MaineCare, makes provisional payments in a manner consistent with this Rule and agrees to submit to the jurisdiction of the Superintendent for the limited purpose of resolving disputes and enforcing the plan’s provisional payment obligation, the plan may file a notice of offset with the workers’ compensation carrier pursuant to this Section. The workers’ compensation carrier shall honor such notices of offset as if they had been filed by health carriers.
Violation of this Rule is subject to the penalties provided in 24-A M.R.S.A. § 12-A.
If any section, term, provision, or application of this Rule shall be adjudged invalid for any reason, such judgment shall not impair or invalidate any other section, term, provision, or application, and the remainder of this Rule shall continue in full force and effect.
The effective date of this Rule is June 27, 1990. This Rule shall apply to all claims that have not been finally resolved by that date. The 2002 Amendments are effective June 29, 2002, and shall apply to all claims filed on or after that date. The 2005 Amendments are effective July 31, 2005.
STATUTORY AUTHORITY: 39-A M.R.S.A. §222(3); 24-A M.R.S.A. §212.
EFFECTIVE DATE:
June 27, 1990
EFFECTIVE DATE (ELECTRONIC CONVERSION):
January 14, 1997
AMENDED:
June 9, 2002
NON-SUBSTANTIVE CORRECTION:
February 28, 2003 - spelling in the first paragraph
AMENDED:
July 31, 2005 – filing 2005-299