CHAPTER 99
H.P. 179 - L.D. 234
An Act to Extend Access to Chiropractic Care under Health Maintenance Organization Managed Care Plans
Be in enacted by the People of the State of Maine as follows:
Sec. 1. 24-A MRSA �4236, sub-�3, as enacted by PL 1995, c. 350, �1, is amended to read:
3. Self-referrals for chiropractic care. A health maintenance organization must provide benefits to an enrollee who utilizes the services of a chiropractic provider by self-referral under the following conditions.
A. An enrollee may utilize the services of a participating chiropractic provider within the enrollee's health maintenance organization for 3 weeks or a maximum of 12 visits, whichever occurs first, of acute care treatment without the prior approval of a primary care provider of the health maintenance organization. For purposes of this subsection, "acute care treatment" means treatment for accidental bodily injury or sudden, severe pain that affects the ability of the enrollee to engage in the normal activities, duties or responsibilities of daily living.
B. Within 3 working days of the first consultation, the participating chiropractic provider shall send to the primary care provider a report containing the enrollee's complaint, related history, examination, initial diagnosis and treatment plan. If the chiropractic provider fails to send a report to the primary care provider within 3 working days, the health maintenance organization is not obligated to provide benefits for chiropractic care and the enrollee is not liable to the chiropractic provider for any unpaid fees.
C. If the enrollee and the participating chiropractic provider determine that the condition of the enrollee has not improved after 3 weeks of treatment or a maximum of 12 visits, the participating chiropractic provider shall discontinue treatment and refer the enrollee to the primary care provider.
D. If the chiropractic provider recommends treatment beyond 3 weeks or a maximum of 12 visits, the participating chiropractic provider shall send to the primary care provider a report containing information on the enrollee's progress and outlining a treatment plan for extended chiropractic care of up to 5 more weeks or a maximum of 12 more visits, whichever occurs first.
E. Without the approval of the primary care provider, an enrollee may not receive benefits for more than 36 visits to a participating chiropractic provider in a 12-month period. After a maximum of 36 visits, an enrollee's continuing chiropractic treatment must be authorized by the primary care provider.
In the provision of chiropractic services under this subsection, a participating chiropractic provider is liable for a professional diagnosis of a mental or physical condition that has resulted or may result in the chiropractic provider performing duties in a manner that endangers the health or safety of an enrollee.
The provisions of this subsection apply to all health maintenance organization contracts, except a contract between a health maintenance organization and the State Employee Health Insurance Program.
This subsection takes effect January 1, 1996 and is repealed March 1, 1998.
Sec. 2. Report required. The Bureau of Insurance shall submit a report to the joint standing committee of the Legislature having jurisdiction over insurance matters of the 119th Legislature by January 1, 1999 on the claims experience of health maintenance organizations related to self-referrals of chiropractic care under the Maine Revised Statutes, Title 24-A, section 4236. The report must include the total amount of claims paid for chiropractic services by health maintenance organizations, the total amount of claims paid for self-referred chiropractic services, the total number of self-referrals for chiropractic care, the average cost of those claims and the number of complaints received by the Bureau of Insurance regarding access to chiropractic care in health maintenance organization managed care plans.
See title page for effective date.
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