Senator Karen Mayne proposes the following substitute bill:


1     
WORKERS' COMPENSATION COORDINATION OF

2     
BENEFITS AMENDMENTS

3     
2018 GENERAL SESSION

4     
STATE OF UTAH

5     
Chief Sponsor: Karen Mayne

6     
House Sponsor: James A. Dunnigan

7     

8     LONG TITLE
9     General Description:
10          This bill modifies provisions related to the coordination between workers'
11     compensation benefits and health benefit plans.
12     Highlighted Provisions:
13          This bill:
14          ▸     modifies a requirement that the Labor Commission provide notice to a health
15     benefit plan of the filing of an application for a hearing;
16          ▸     requires the Labor Commission to allow a health benefit plan to become a party to a
17     hearing regarding a workers compensation claim; and
18          ▸     eliminates language that provides for a repeal of provisions related to the
19     coordination between workers' compensation benefits and health benefit plans.
20     Money Appropriated in this Bill:
21          None
22     Other Special Clauses:
23          None
24     Utah Code Sections Affected:
25     AMENDS:

26          31A-22-619.6, as last amended by Laws of Utah 2016, Chapter 348
27          34A-2-213, as last amended by Laws of Utah 2016, Chapter 348
28          63I-1-231, as last amended by Laws of Utah 2017, Chapters 53 and 181
29          63I-1-234, as last amended by Laws of Utah 2016, Chapter 39
30     

31     Be it enacted by the Legislature of the state of Utah:
32          Section 1. Section 31A-22-619.6 is amended to read:
33          31A-22-619.6. Coordination of benefits with workers' compensation claim --
34     Health insurer's duty to pay.
35          (1) As used in this section:
36          (a) "Employee" means an employee, worker, or operative as defined in Section
37     34A-2-104.
38          (b) "Employer" is as enumerated and defined in Section 34A-2-103.
39          (c) "Health benefit plan":
40          (i) means the same as that term is defined in Section 31A-1-301;
41          (ii) includes:
42          (A) a health maintenance organization;
43          (B) a third party administrator that offers, sells, manages, or administers a health
44     benefit plan; and
45          (C) the Public Employees' Benefit and Insurance Program created in Section
46     49-20-103; and
47          (iii) excludes a health benefit plan offered by an insurer that has a market share in the
48     state's fully insured market that is less than 2%, as determined in the department's annual
49     Market Share Report published by the department.
50          (d) "Workers' compensation carrier" means any of the entities an employer may use to
51     provide workers' compensation benefits for its employees under Section 34A-2-201.
52          (e) "Workers' compensation claim" means a claim for compensation for medical
53     benefits under Title 34A, Chapter 2, Workers' Compensation Act, or Title 34A, Chapter 3,
54     Utah Occupational Disease Act.
55          (2) (a) For medical claims incurred on or after July 1, 2014, an employee's health
56     benefit plan may not delay or deny payment of benefits due to the employee under the terms of

57     a health benefit plan by claiming that treatment for the employee's injury or disease is the
58     responsibility of the employer's workers' compensation carrier if:
59          (i) the employee or a health care provider on behalf of an employee files an application
60     for hearing regarding the workers' compensation claim with the Division of Adjudication under
61     Section 34A-2-801; and
62          (ii) the health benefit plan received a notice from the Labor Commission that an
63     application for hearing was filed in accordance with Subsection (2)(a)(i).
64          (b) The Labor Commission shall provide the notice required by Subsection (2)(a)(ii) in
65     accordance with Subsection 34A-2-213(2).
66          (c) Upon request by a health benefit plan that receives notice under Subsection
67     34A-2-213(2)(a), the Labor Commission shall allow the health benefit plan to become a party
68     to a hearing under Subsection (2)(a)(i).
69          (3) A health benefit plan that receives a medical claim from the employee or a health
70     care provider and a notice from the Labor Commission in accordance with Subsection (2):
71          (a) shall pay the medical claim directly to the health care provider in the dollar amount
72     paid under the limits, terms, and conditions of the employee's health benefit plan; and
73          (b) may send a notice to the Labor Commission or the attorney for the injured worker
74     informing the parties that the health benefit plan paid a claim under the provisions of this
75     section.
76          (4) If the claims for medical services paid pursuant to Subsection (3) are determined to
77     be compensable by the workers' compensation carrier in a final order under Section 34A-2-801
78     or under the terms of a settlement agreement under Section 34A-2-420, the workers'
79     compensation carrier shall pay the health benefit plan and employee in accordance with
80     Subsection 34A-2-213(3)(b).
81          (5) (a) A health care provider who receives payment for a medical claim from a health
82     benefit plan under the provisions of Subsection (3) may not request additional payment for the
83     medical claim from the workers' compensation carrier if the final order under Section
84     34A-2-801 or terms of the settlement agreement under Section 34A-2-420 determine that the
85     medical claim was compensable by the workers' compensation carrier.
86          (b) A health benefit plan that is reimbursed under the provisions of Subsection
87     34A-2-213(3) for a medical claim may not seek reimbursement or autorecovery from the health

88     care provider for any difference between the amount of the claim paid by the health benefit
89     plan and the reimbursement to the health benefit plan by the workers' compensation carrier
90     under Subsection 34A-2-213(3).
91          (c) If a final order of the Labor Commission under Section 34A-2-801 or the terms of a
92     settlement agreement under Section 34A-2-420 determines that a medical claim is
93     compensable by the workers' compensation carrier, the workers' compensation carrier may not
94     seek reimbursement or autorecovery from a health care provider for any part of the medical
95     claim that is the responsibility of the workers' compensation carrier under the order or
96     settlement agreement.
97          [(6) This section sunsets in accordance with Section 63I-1-231.]
98          Section 2. Section 34A-2-213 is amended to read:
99          34A-2-213. Coordination of benefits with health benefit plan -- Timely payment
100     of claims.
101          (1) (a) This section applies if:
102          (i) a health benefit plan paid medical claims under Section 31A-22-619.6; and
103          (ii) the Labor Commission under 34A-2-801 issued an order or approved the terms of a
104     settlement agreement under Section 34A-2-420, which:
105          (A) found that the medical claims are compensable under Title 34A, Chapter 2,
106     Workers' Compensation Act, or Title 34A, Chapter 3, Utah Occupational Disease Act; and
107          (B) is final under Section 34A-2-801.
108          (b) For purposes of this section, "workers' compensation carrier" means any of the
109     entities an employer may use to provide workers' compensation benefits for its employees
110     under Section 34A-2-201.
111          (2) (a) The Labor Commission shall provide a health benefit plan with notice that an
112     application for hearing has been filed in accordance with Subsection 31A-22-619.6(2)(a)(i) [if
113     either the employee or a health care provider requests that the commission send the notice].
114          (b) The Labor Commission shall prepare and provide notice to an injured employee of
115     the employee's right to payment by the employee's health benefit plan under Section
116     31A-22-619.6. The notice provided under this Subsection (2) shall include the process the
117     employee shall follow to obtain payment from a health benefit plan for a medical claim that is
118     the subject of an application for hearing under Section 34A-2-801.

119          (3) (a) The Labor Commission shall, within three business days after the date on which
120     the order under Section 34A-2-801 or approval of the terms of a settlement agreement under
121     Section 34A-2-420 is signed by the administrative law judge, send a copy of the order or terms
122     of the settlement agreement to:
123          (i) a health benefit plan that made payments under Section 31A-22-619.6;
124          (ii) the workers' compensation carrier; and
125          (iii) the injured worker.
126          (b) The workers' compensation carrier shall, within 15 business days after the day on
127     which the Labor Commission's order under Section 34A-2-801 or settlement agreement under
128     Section 34A-2-420 is final, pay:
129          (i) the health benefit plan, in the amount the plan paid to the health care provider for
130     medical claims that are compensable under the order or the terms of the settlement agreement,
131     plus interest accrued at the rate of 8% per annum from the date the health benefit plan paid the
132     medical claims until the date the workers' compensation carrier reimburses the health benefit
133     plan, unless, in settlement negotiations, the health benefit plan agreed to waive, in whole or in
134     part, reimbursement for medical claims paid, interest accrued, or both; and
135          (ii) the employee, in the amount of:
136          (A) any co-payments, coinsurance, deductibles, or other out-of-pocket expenses paid or
137     incurred by the employee; and
138          (B) interest accrued at the rate of 8% per annum from the date the employee paid the
139     expenses described in Subsection (3)(b)(ii)(A) until the date the workers' compensation carrier
140     reimburses the employee.
141          (4) If the Labor Commission determines that a workers' compensation carrier did not
142     make the payment required by Subsection (3) within the time period required in Subsection (3),
143     the commissioner shall:
144          (a) assess and collect a penalty from the workers' compensation carrier in:
145          (i) the amount of $500 for failure to pay the amount required by Subsections (3)(b)(i)
146     and (ii) within the period of time required by Subsections (3)(b)(i) and (ii); and
147          (ii) an additional amount of $500 for each calendar month:
148          (A) that accrues after the penalty is assessed under Subsection (4)(a)(i); and
149          (B) for which the amount required by Subsections (3)(b)(i) and (ii) are not paid;

150          (b) deposit any penalties collected under this Subsection (4) into the Uninsured
151     Employers' Fund created in Section 34A-2-704; and
152          (c) notify the Utah Insurance Department of the workers' compensation carrier's failure
153     to pay the health benefit plan or the employee in accordance with this section.
154          (5) The penalty imposed by Subsection (4) is in addition to any action taken or penalty
155     imposed by the Utah Insurance Department under Title 31A, Insurance Code.
156          (6) The commission may adopt administrative rules in accordance with Title 63G,
157     Chapter 3, Utah Administrative Rulemaking Act, to:
158          (a) establish procedures for:
159          (i) assessing and collecting penalties under Subsection (4); and
160          (ii) providing notice as required by this section; and
161          (b) enforce the provisions of this section.
162          [(7) This section sunsets in accordance with Section 63I-1-234.]
163          Section 3. Section 63I-1-231 is amended to read:
164          63I-1-231. Repeal dates, Title 31A.
165          (1) Section 31A-2-217, Coordination with other states, is repealed July 1, 2023.
166          (2) Section 31A-22-615.5 is repealed July 1, 2022.
167          [(3) Section 31A-22-619.6, Coordination of benefits with workers' compensation
168     claim--Health insurer's duty to pay, is repealed on July 1, 2018.]
169          [(4)] (3) Section 31A-22-642, Insurance coverage for autism spectrum disorder, is
170     repealed on January 1, 2019.
171          Section 4. Section 63I-1-234 is amended to read:
172          63I-1-234. Repeal dates, Titles 34 and 34A.
173          (1) Section 34A-2-202.5 is repealed December 31, 2020.
174          (2) Section 34A-2-705 and Subsection 59-9-101(2)(c)(iv) are repealed July 1, 2018.
175          [(3) Section 34A-2-213, Coordination of benefits with health benefit plan -- Timely
176     payment of claims, is repealed July 1, 2018.]