Florida Regulations 69O-189.014

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§ 69O-189.014 Workers' Compensation Rating Plan for Managed Care Premium Credits.

(1) Scope. This rule governs the approval of rating plans for workers' compensation that provide for premium credits not to exceed 10 percent for employers that utilize managed care arrangements as certified by the Agency for Health Care Administration pursuant to the authority set forth in Chapter 93-415, Laws of Florida.

(2) Definitions. (a) "Department" means the Department of Insurance. (b) "Insurer" means an authorized insurer under the Florida Insurance Code and self-insurance funds as defined under Section 624.461, Florida Statutes. (c) "Managed care arrangement" means a workers' compensation managed care arrangement as defined under Section 440.134(1)(g), Florida Statutes. (d) "Medical care coordinator" means a primary care provider within a provider network as defined under Section 440.134(1)(i), Florida Statutes. (e) "Provider network" means a panel of health care providers and health care facilities as defined under Section 440.134(1)(j), Florida Statutes. (3) Rating Plan Approval Filing Requirements. An insurer may file with the department a rating plan for employers that utilize an approved workers' compensation managed care arrangement. Every such filing shall contain separate sections setting out the following information: (a) Proposed effective date of premium credit. (b) Proposed amount of premium credit. (c) Certification from Agency for Health Care Administration for managed care arrangement. (d) An explicit statement of all factors the insurer considers relevant to justify the proposed premium credit based on sound actuarial principles. (e) The specific geographic area to be covered by the managed care arrangement and an estimate of the number of employees, by county, expected to be covered by the managed care arrangement. (f) The estimated savings for medical and indemnity losses. (g) A description of the financial arrangements between the insurer and the provider network, showing any cost savings, risk assumption and risk sharing. The documentation shall clearly define the financial responsibility of all parties for all contingencies and shall include a copy of contracts entered into by the insurer. Adequate financial incentives to control utilization and costs shall be provided as substantiation for a high premium credit. (h) A description of the incentives and procedures for health care providers to encourage a rapid return to work, to minimize indemnity payments, and to assist the employer in the implementation of a return-to-work program. Significant indemnity savings derived from return-to-work activities are necessary to substantiate a high premium credit. (i) A description of the medical care coordinator and the coordinator's procedures. If the medical care coordinator is not a practicing physician who is actually treating the injured workers, then the insurer shall justify the arrangement from a cost savings standpoint. (j) A description of the conditions under which an injured employee may obtain treatment outside of the provider network. The insurer shall explain any penalties or deterrent for treatment outside the provider network other than emergency care. The insurer shall provide an estimate of the percentage of injuries for employees covered by the managed care arrangement which will be treated outside the network. The insurer shall provide a list, by county, of the number of providers and the number of distinct practices or professional associations by type of specialty, including hospitals and diagnostic facilities. The managed care arrangement shall have a full scope closed network of providers which has a sufficient number of participating providers to render quality and timely medical treatment and to ensure that there are providers from different practices or professional associations for second opinions, for independent medical examinations, and to allow a change of provider, in order to substantiate a high premium credit. Additionally, the managed care arrangement provider network shall render all covered services except for emergency care or urgent care outside of the service area unless the managed care coordinator determines that the medically necessary treatment is not available or accessible in the network, in order to substantiate a high premium credit. (k) A description of the quality assurance and utilization review program established pursuant Section 440.134(6)(c), Florida Statutes. Specific details shall be provided on the extent to which the program is anticipated to contain costs. The insurer shall have a quality assurance and utilization review program which is based on clinical guidelines or which measures providers against their peers to substantiate a high premium credit. (l) The application form to be used by employers to apply for the premium credit. (m) The rating plan showing where the premium credit will apply in calculating workers¬タル compensation premiums. The rating plan shall address both experience rated policies and retrospectively rated policies. The rating plan shall address how the credit will be determined if not all of the employees are in an area covered by the managed care arrangement or if the provider network expands or contracts to include additional counties. (4) Effective Date. A filing for the managed care premium credit shall not be used by the insurer until it is specifically approved by the department. The insurer shall not use the managed care premium credit in any solicitation or advertisement or otherwise publicize the premium credit before the premium credit is approved by the department. (5) The approval and the level of discount shall be based on sound actuarial principles. Specific Authority 624.308(1) FS. Law Implemented 440.134, 624.307(1), 624.461, 624.482, 626.9541(1)(a), (b), (e), 627.091, 627.101, 627.191 FS., Section 95 of Chapter 93-415, Laws of Florida. History-New 8-15-94.