Or. Admin. Code § 436-015-0037 - MCO-Insurer Contracts
(1) An MCO
must provide comprehensive medical services to all enrolled workers covered by
the MCO-insurer contract according to the MCO's certification.
(2) An MCO may not contract exclusively with
a single insurer. However, an MCO has up to one year from the effective date of
its first contract to obtain contracts with more than one insurer. If the MCO
has not obtained additional contracts within this time period, the MCO must
provide the director with a report documenting the MCO's efforts to obtain
additional contracts.
(3) An MCO
may contract only with insurers. The contract must include the following terms
and conditions:
(a) Who is governed by the
contract;
(b) The covered place of
employment must be within the authorized geographic service area;
(c) Insurers may contract with multiple MCOs
to provide coverage for employers. All workers at any specific employer's
location must be governed by the same MCO(s). When insurers contract with
multiple MCOs each worker must have initial choice at the time of injury to
select which MCO will manage their care except when the employer provides a
coordinated health care program;
(d) Workers enrolled in anMCO must receive
medical services as prescribed by the terms and conditions of the contract;
and
(e) A continuity of care
provision specifying how workers will receive medical services on open claims,
including the following:
(A) Upon enrollment,
allowing workers to continue to treat with the current medical service
providers for at least 14 days after the mailing date of the notice of
enrollment; and
(B) Upon
termination or expiration of the MCO-insurer contract, allowing workers to
continue treatment under ORS
656.245(4)(a).
(4) Notwithstanding the
requirements of this rule, failure of the MCO to provide medical services does
not relieve the insurers of their responsibility to ensure benefits are
provided to workers under ORS chapter 656.
Notes
Statutory/Other Authority: ORS 656.260 & 656.726(4)
Statutes/Other Implemented: ORS 656.260 & 656.245
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