BEFORE THE DEPARTMENT OF LABOR AND INDUSTRY

STATE OF MONTANA

 

 

In the matter of the proposed adoption                   ) NOTICE OF PUBLIC HEARING

of NEW RULES I, II, and III, all related to                 ) ON PROPOSED ADOPTION

the medical benefits payable by                              )

the uninsured employers fund                                  )

 

 

TO: All Concerned Persons

 

 

1. On August 31, 2007, at 10:00 a.m., the Department of Labor and Industry (department) will hold a public hearing to be held in the first floor conference room (Room 104), Walt Sullivan Building, 1327 Lockey Avenue, Helena, MT to consider the proposed adoption of the above-stated rules.

 

 

2. The department will make reasonable accommodations for persons with disabilities who wish to participate in this public hearing or need an alternative accessible format of this notice. If you require an accommodation, contact the department no later than 5:00 p.m., on August 24, 2007, to advise us of the nature of the accommodation that you need. Please contact the Workers' Compensation Regulations Bureau, Employment Relations Division, Department of Labor and Industry, Attn: Cathy Brown, P.O. Box 8011, Helena, MT 59624-8011; telephone (406) 444-7720; fax (406) 444-3465; TDD (406) 444-5549; or e-mail cabrown@mt.gov.

 

 

3. The proposed new rules provide as follows:

 

 

NEW RULE I LIMITATION ON EXPENDITURES FOR MEDICAL BENEFITS PAYABLE BY THE UEF -- APPLICABILITY (1) Pursuant to 39-71-503 and 39-71-510, MCA, the maximum aggregate expenditure for medical benefits per claim payable by the UEF is $100,000. The $100,000 limitation is based on the amount actually paid by the UEF, after applying the fee schedules adopted pursuant to 39-71-704 and 39-71-727, MCA, to the medical services.

(2) The limitation applies to primary medical services and to those secondary medical services approved by the UEF.

(3) To the extent practicable, the UEF will reimburse providers for services provided at the earliest date or time before reimbursing for services provided at a later date or time. In the event of a catastrophic injury, however, it may not be feasible to identify the exact timing of the provision of services, and multiple providers may be simultaneously rendering services to the injured worker. The UEF reserves the right to make reasonable judgments regarding which services will be reimbursed first.

(4) The term "medical benefits", as used in this rule, includes:

(a) provider fees, whether for charges for direct services or for facility-related fees;

(b) prescription medications;

(c) allowed medical supplies; and

(d) durable medical equipment.

(5) This rule applies to claims arising on or after July 1, 2007.

 

 

AUTH: 39-71-203, MCA

IMP: 39-71-503, 39-71-510, 39-71-704, 39-71-727, MCA

 

 

Reason: There is reasonable necessity to adopt NEW RULE I in order to implement and clarify certain provisions contained in Chapter 48, Laws of 2007 (House Bill 65). For example, it is reasonably necessary to clarify that the Workers' Compensation Act medical and prescription drug fee schedules apply to a claim paid by the UEF until the $100,000 limit is reached.

 

 

NEW RULE II RIGHTS OF THIRD-PARTY PROVIDERS AFTER THE UEF REACHES $100,000 MEDICAL BENEFIT EXPENDITURE LIMITATION -- APPLICABILITY (1) Providers of medical services, referred to in 39-71-508, MCA, as "third-party providers", who are directly affected by the UEF's invocation of the $100,000 aggregate expenditure limit for medical benefits have a right to bring a legal action against the uninsured employer for unpaid charges for medical services furnished to the injured worker as follows:

(a) The UEF's payment of the amount allowed by the fee schedule constitutes payment in full for the charges for a given medical service. After the UEF has reimbursed all services that fall within its aggregate expenditure limit, a medical provider may pursue the uninsured employer for the full amount of reasonable and customary charges incurred for services rendered that were not reimbursed. The UEF will notify a provider to which services a given reimbursement applies.

(b) The uninsured employer has liability only for medical services directly related to those conditions arising out of the industrial injury or occupational disease which the UEF accepted as a claim.

(2) Pursuant to 39-71-508 and 39-71-743, MCA, the injured worker is not liable to the provider of medical services for the difference between the amount payable to the provider pursuant to the fee schedules and the charges billed by the provider or for the services provided that are not reimbursed after the $100,000 expenditure limit is reached.

(3) This rule applies to claims arising on or after July 1, 2007.

 

 

AUTH: 39-71-203, MCA

IMP: 39-71-503, 39-71-508, 39-71-510, 39-71-704, 39-71-727, 39-71-743, MCA

 

 

Reason: There is reasonable necessity to adopt NEW RULE II in order to implement and clarify certain provisions contained in Chapter 48, Laws of 2007 (House Bill 65). For example, it is reasonably necessary to clarify that third-party providers as used in the statute are providers of primary medical services. It is also necessary to clarify that although services reimbursed by the UEF are subject to the Workers' Compensation Act fee schedules, services provided that fall above the $100,000 limit are not subject to the fee schedules.

 

 

NEW RULE III RIGHTS OF THIRD-PARTY PROVIDERS UPON THE UEF'S PROPORTIONATE REDUCTION IN BENEFIT PAYMENTS -- APPLICABILITY

(1) In addition to the provisions of [NEW RULE II], providers of medical services who are subject to a proportionate reduction in reimbursement payments from the UEF pursuant to 39-71-510, MCA, have a right to bring legal action against the uninsured employer for unpaid charges for medical services furnished to the injured worker as follows:

(a) If the UEF does not pay the fee schedule amount due to a proportionate reduction, a medical provider may pursue the uninsured employer for the unpaid portion of the fee schedule amount. The UEF will notify a provider to which services a proportionate reduction was applied.

(b) The uninsured employer has liability for primary medical services and secondary medical services approved by the UEF which are directly related to those conditions arising out of the industrial injury or occupational disease which the UEF accepted as a claim up to the $100,000 expenditure limit.

(2) Pursuant to 39-71-508 and 39-71-743, MCA, the injured worker is not liable to the provider of medical services for the difference between the amount paid by the UEF and the fee schedule.

(3) This rule applies to claims arising on or after July 1, 2007.

 

 

AUTH: 39-71-203, MCA

IMP: 39-71-503, 39-71-508, 39-71-510, 39-71-704, 39-71-727, 39-71-743, MCA

 

 

Reason: There is reasonable necessity to adopt NEW RULE III in order to implement and clarify certain provisions contained in Chapter 48, Laws of 2007 (House Bill 65). For example, it is reasonably necessary to clarify that even if a claim is subject to the proportion reduction allowed by 39-71-510, MCA, the fee schedules still apply until the $100,000 expenditure limit is reached.

 

 

4. Concerned persons may present their data, views, or arguments, either orally or in writing, at the hearing. Written data, views, or arguments may also be submitted to: Keith Messmer, Bureau Chief, Workers' Compensation Regulations Bureau, Employment Relations Division, Department of Labor and Industry, P.O. Box 8011, Helena, Montana 59624-8011; by facsimile to (406) 444-3465; or by e-mail to kmessmer@mt.gov, and must be received no later than 5:00 p.m., September 7, 2007.

 

 

5. An electronic copy of this Notice of Public Hearing is available through the department's web site at http://dli.mt.gov/events/calendar.asp, under the Calendar of Events, Administrative Rules Hearings Section. The department strives to make the electronic copy of this Notice of Public Hearing conform to the official version of the Notice, as printed in the Montana Administrative Register, but advises all concerned persons that in the event of a discrepancy between the official printed text of the Notice and the electronic version of the Notice, only the official printed text will be considered. In addition, although the department strives to keep its web site accessible at all times, concerned persons should be aware that the web site may be unavailable during some periods, due to system maintenance or technical problems, and that a person's difficulties in sending an e-mail do not excuse late submission of comments.

 

 

6. The department maintains a list of interested persons who wish to receive notices of rulemaking actions proposed by this agency. Persons who wish to have their name added to the list shall make a written request, which includes the name and mailing address of the person to receive notices and specifies that the person wishes to receive notices regarding all Department of Labor and Industry administrative rulemaking proceedings or other administrative proceedings. Such written request may be mailed or delivered to the Department of Labor and Industry, attention: Mark Cadwallader, 1327 Lockey Avenue, P.O. Box 1728, Helena, Montana 59624-1728, faxed to the department at (406) 444-1394, e-mailed to mcadwallader@mt.gov, or may be made by completing a request form at any rules hearing held by the agency.

 

 

7. The bill sponsor notice requirements of 2-4-302, MCA, apply and have been fulfilled. The primary sponsor of House Bill 65 was notified on April 3, 2007, by regular mail.

 

 

8. The department's Hearings Bureau has been designated to preside over and conduct this hearing.

 

 

 

/s/ MARK CADWALLADER                                    /s/ KEITH KELLY

Mark Cadwallader                                                    Keith Kelly, Commissioner

Alternate Rule Reviewer                                          DEPARTMENT OF LABOR AND INDUSTRY

 

 

 

 

Certified to the Secretary of State July 30, 2007