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The latest legislative and regulatory activity that impacts you and the services we provide

Policy Matters Brief - May 1, 2024

May 1, 2024 · Public Policy & Regulatory Affairs Team

California workers’ comp opioid treatment guidelines updated

Effective March 27, 2024, the California Division of Workers’ Compensation (DWC) adopted updates to its Medical Treatment Utilization Schedule (MTUS) opioid treatment guidelines. The revisions incorporate the latest published recommendations from the American College of Occupational and Environmental Medicine (ACOEM) for opioids and describe the appropriate use of opioids as part of an overall multidisciplinary treatment regimen for acute, sub-acute, post-operative, and chronic non-cancer pain. The guidelines apply when opioid medications are being considered as part of a treatment regimen. Although California workers’ compensation law states that MTUS guidelines are presumptively correct regarding the extent and scope of medical treatment, this presumption can be rebutted and may be controverted by a preponderance of medical evidence proving that a variance from the guidelines is reasonably required to cure or relieve injured workers from the effects of their industrial injuries. More information can be viewed online here.

More details on policy actions related to medical treatment guidelines can be found on our Legislative and Regulatory Tracker tool, which allows users to filter pending and recently adopted regulations by industry, topic and disposition (status), and then click on an individual state on the map. Select “Treatment Guidelines” under “Select a Topic.”

Pennsylvania continues to contemplate AWP issue

As the legal battle of appeals related to usage of REDBOOK® AWP as a pricing source for pharmacy reimbursement in Pennsylvania continues, the state’s Department of Labor and Industry is actively reviewing the legal issues and regulatory processes. In its recent quarterly medical fee schedule update, the Department stated “Red Book. The Bureau is aware of the Commonwealth Court’s decision in the Federated Insurance Case dated January 2, 2024. The decision is being reviewed. The Bureau will take appropriate steps to comply with the court’s decision.” A recent request for a stay of the lower court’s decision – requested by a provider petitioner – was denied by an appellate court and the case now moves to the State Supreme Court for review. More information on the full quarterly fee schedule update can be found here.

Louisiana Legislature considering work comp. fee schedules

The Louisiana House of Representatives is considering two bills related to creating medical fee schedules and setting parameters within those fee schedules for workers’ compensation. The first bill, House Bill 863, would require that by January 1, 2026, a reimbursement fee schedule based upon Medicare would be crafted, taking into consideration fee schedule elements of surrounding states. The second bill, House Bill 870, limits reimbursement for medical services in workers’ compensation claims to one and a half times what Medicare reimburses and also addresses reimbursement for services lacking a Medicare reimbursement rate.

Kentucky law expands workers’ comp “physician” definition to include out-of-state providers

Kentucky House Bill 401, signed into law in early April, amends the state workers’ compensation law by expanding the general definition for “physician” to include out-of-state practitioners acting within the scope of their license or other credentials required in the jurisdiction in which they are authorized to practice. It is important to note that “physician” under existing law and as amended by this bill also includes surgeons, psychologists, optometrists, dentists, podiatrists, as well as osteopathic and chiropractic practitioners. This expanded definition has implications for providers who treat injured workers and prescribe or refer additional treatment for them, and may also determine who can perform certain utilization review functions. HB 401 also amends the definition for “physician” in reference to testifying in workers’ compensation administrative hearings in order to permit physicians retired in good standing who were licensed in Kentucky.

Texas issues clarification regarding pharmacy first fill

The Texas Division of Workers’ Compensation (TDWC) recently released a “Memo to System Participants,” which provides an outline or restatement of existing regulations for system stakeholders. The memo, titled “Preventative Treatment Claims Handling”, provides a “reminder” to system stakeholders regarding the first fill policy in place under TDWC’s Drug Formulary. TDWC reminds all pharmacy stakeholders to comply with the first fill requirements as outlined in 28 TAC Sections 134.501 and 137.100. The memo and other TDWC memos over the years can be found here.

Wisconsin workers’ comp medical fee schedule legislation fails

Two Wisconsin workers’ compensation companion bills that would have required the adoption of a medical fee schedule and amended PTSD coverage for first responders were among several other bills that failed to pass due to not meeting a prescribed deadline. The two bills, Senate Bill 992 and Assembly Bill 1074, saw no formal movement since hearings in the first committees they were referred to in February. The bills were based on “agreed upon” proposals approved by the state’s Council on Workers’ Compensation (also referred to as the Worker's Compensation Advisory Council) in late November of 2023. While existing law already prescribes a pharmacy fee schedule, medical providers and services currently have no specific fee schedule and disputes are determined based on certified databases of provider fees. For more background on the bill’s contents (including additional PTSD provisions), please refer to our prior update from February of this year.

Alabama bill would add a Parkinson’s disability benefit presumption for firefighters

Alabama House Bill 223 would, if passed and signed into law, add Parkinson's disease to the list of recognized occupational diseases for firefighters under various disability benefits laws. Existing law provides that firefighters may be paid benefits for disability or death caused by a “firefighter's occupational disease,” which currently includes hypertension, heart disease, respiratory disease, cancer, AIDS, and hepatitis. HB 223 adds to that list Parkinson's disease that manifests itself in a firefighter while the firefighter is in the service of the city and was exposed to a known toxin associated with an increased risk of Parkinson's disease. In that case, Parkinson's disease is to be presumed to arise out of and in the course of the firefighter's employment. This bill would also amend the term “AIDS” to instead state “HIV.” HB 223 was passed out of the House on April 11 and is pending in the Senate.

Texas reviewing work comp. reimbursement rules

The Texas Division of Workers’ Compensation (TDWC) recently announced it will be reviewing all sections of reimbursement rules related to “Insurance Carriers: Notices, Payments and Reporting.” These include compensation procedures (employers in Chapter 120); compensation procedures (claimants in Chapter 122); and notices, payments and reporting (insurers in Chapter 124). The TDWC is seeking public comment on the need to readopt, repeal or modify the existing regulatory language. More information can be found here, and comments are due by 5 p.m. on May 13, 2024.

Additional Optum resources:

For more information on these policy developments and others we have been tracking this year, be sure to visit our Legislative and Regulatory Tracker. Bills or regulations can be filtered by insurance line, topic, status and jurisdiction.

If you have questions on these or any other public policy developments, please contact our team at OptumWC.PolicyMatters@optum.com.

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