§ 31A-22-619.6. Coordination of benefits with workers' compensation claim -- Health insurer's duty to pay. (Effective 7/1/2014)

(1) As used in this section:

(a) "Employee" means an employee, worker, or operative as defined in Section 34A-2-104.

(b) "Employer" is as enumerated and defined in Section 34A-2-103.

(c) "Health benefit plan":

(i) is as defined in Section 31A-1-301;

(ii) includes:

(A) a health maintenance organization;

(B) a third party administrator that offers, sells, manages, or administers a health benefit plan; and

(C) the Public Employees' Benefit and Insurance Program created in Section 49-20-103; and

(iii) excludes a health benefit plan offered by an insurer that has a market share in the state's fully insured market that is less than 2%, as determined in the department's annual Market Share Report published by the department.

(d) "Workers' compensation carrier" means any of the entities an employer may use to provide workers' compensation benefits for its employees under Section 34A-2-201.

(e) "Workers' compensation claim" means a claim for compensation for medical benefits under Title 34A, Chapter 2, Workers' Compensation Act, or Title 34A, Chapter 3, Utah Occupational Disease Act.

(2)

(a) For medical claims incurred on or after July 1, 2014, an employee's health benefit plan may not delay or deny payment of benefits due to the employee under the terms of a health benefit plan by claiming that treatment for the employee's injury or disease is the responsibility of the employer's workers' compensation carrier if:

(i) the employee or a health care provider on behalf of an employee files an application for hearing regarding the workers' compensation claim with the Division of Adjudication under Section 34A-2-801; and

(ii) the health benefit plan received a notice from the Labor Commission that an application for hearing was filed in accordance with Subsection (2)(a)(i).

(b) The Labor Commission shall provide the notice required by Subsection (2)(a)(ii) in accordance with Subsection 34A-2-213(2).

(3) A health benefit plan that receives a medical claim from the employee or a health care provider and a notice from the Labor Commission in accordance with Subsection (2):

(a) shall pay the medical claim directly to the health care provider in the dollar amount paid under the limits, terms, and conditions of the employee's health benefit plan; and

(b) may send a notice to the Labor Commission or the attorney for the injured worker informing the parties that the health benefit plan paid a claim under the provisions of this section.

(4) If the claims for medical services paid pursuant to Subsection (3) are determined to be compensable by the workers' compensation carrier in a final order or under the terms of a settlement agreement under Section 34A-2-801, the workers' compensation carrier shall pay the health benefit plan and employee in accordance with Subsection 34A-2-213(3)(b).

(5)

(a) A health care provider who receives payment for a medical claim from a health benefit plan under the provisions of Subsection (3) may not request additional payment for the medical claim from the workers' compensation carrier if the final order or terms of the settlement agreement under Section 34A-2-801 determine that the medical claim was compensable by the workers' compensation carrier.

(b) A health benefit plan that is reimbursed under the provisions of Subsection 34A-2-213(3) for a medical claim may not seek reimbursement or autorecovery from the health care provider for any difference between the amount of the claim paid by the health benefit plan and the reimbursement to the health benefit plan by the workers' compensation carrier under Subsection 34A-2-213(3).

(c) If a final order of the Labor Commission or the terms of a settlement agreement under Section 34A-2-801 determines that a medical claim is compensable by the workers' compensation carrier, the workers' compensation carrier may not seek reimbursement or autorecovery from a health care provider for any part of the medical claim that is the responsibility of the workers' compensation carrier under the order or settlement agreement.

(6) This section sunsets in accordance with Section 63I-1-231.

Enacted by Chapter 417, 2013 General Session