Mass. Gen. Laws ch. 152, sec. 30 — MA Code / Part I / Title XXI / Chapter 152 / Section 30
Adequate and reasonable health care services; preferred health care provider
Status: in_force

Section 30. The insurer shall furnish to an injured employee adequate and reasonable health care services, and medicines if needed, together with the expenses necessarily incidental to such services, and in the case of an injured employee, a physical examination shall be given at least once a year while the employee is hospitalized. Except for the employee's first scheduled appointment, which, pursuant to the terms of a preferred provider arrangement entered into under this section may be required to be with a health care provider within the plan, the employee may select a treating health care professional other than any provided or agreed to by the insurer and may switch to another such professional once. When referred by the treating health care professional to another provider in a particular specialty, the employee may also change once to a different provider in such specialty. In cases of emergency or where the insurer or administrative judge agrees, the employee may seek treatment from additional providers. Where services are provided to employees under this section, the reasonable and necessary cost of such services shall be paid by the insurer. On or before July first, nineteen hundred and ninety-three, the commissioner shall promulgate regulations regarding the provision of adequate and reasonable health care services. In doing so, he shall utilize the treatment guidelines developed and endorsed under the provisions of section thirteen. Any provision of health care services in material compliance with such regulations shall be presumed to be adequate and reasonable. Any material departure from said regulations shall be presumed to be either an inadequate or unreasonable provision of health care services. An employee receiving benefits from the Workers' Compensation Trust Fund may be required to choose a treating physician from a health maintenance organization which has been chosen by the fund. In any instance in which the fund requires such a choice of an employee, the fund shall pay all co-payments, deductibles, or other costs required by the health maintenance organization for necessary and reasonable medical and hospital services under this chapter. In any case where an administrative judge, the reviewing board, the office of education and vocational rehabilitation or the health care services board is of the opinion that the fitting of an employee eligible for compensation with an artificial eye or limb, or other mechanical appliance, will promote his restoration to or continue him in industry, it may be ordered that such employee be provided with such item, at the expense of the insurer. The provisions of this section shall be applicable so long as such services are necessary, notwithstanding the fact that maximum compensation under other sections of this chapter may have been received by the injured employee. Any insurer may enter into a preferred provider arrangement in compliance with the requirements of chapter one hundred and seventy-six I of the General Laws and the regulations thereunder. Notwithstanding any other provision of this chapter, if an insurer enters into a preferred provider arrangement for health care services required under this chapter, those employees who are subject to the arrangement shall receive such care in the manner prescribed by the arrangement; provided, however, that a worker may receive immediate emergency treatment from a health care provider who is not a member of the managed care organization, and the insurer shall pay the reasonable and necessary costs of such treatment. Notwithstanding the provisions of this section, if an employee requests the services of a health care provider licensed or certified under the provisions of chapter one hundred and twelve and such specialty is not represented within the preferred provider organization with whom the employer has contracted, and the employee utilizes the services of such provider, the insurer or preferred provider organization shall pay the reasonable and necessary costs of such service. Said employee shall be allowed to choose any such health care provider. Any insurer, with the written consent of the insured employer may, except as provided by the terms of a collective bargaining agreement, if any, approved under this chapter enter into a preferred provider arrangement for the employees of such employers in compliance with the requirements of chapter one hundred and seventy-six I and the regulations thereunder. If an insurer enters into a preferred provider arrangement for health care services required under this chapter, those employees who are subject to the arrangement shall receive such care in the manner prescribed by the arrangement consistent with this section. Notwithstanding the provisions of this section if an employee requests, for his first scheduled appointment, the services of a health care provider licensed or certified under the provisions of chapter one hundred twelve and the specialty of said health care provider is not represented within the preferred provider organization with which the employer has contracted, and the employee utilizes the services of such provider, the insurer or preferred provider organization shall pay the reasonable and necessary costs of such service as provided under this chapter. In no instance shall employees be required to make copayments or pay deductibles.

Section 30. The insurer shall furnish to an injured employee adequate and reasonable health care services, and medicines if needed, together with the expenses necessarily incidental to such services, and in the case of an injured employee, a physical examination shall be given at least once a year while the employee is hospitalized. Except for the employee's first scheduled appointment, which, pursuant to the terms of a preferred provider arrangement entered into under this section may be required to be with a health care provider within the plan, the employee may select a treating health care professional other than any provided or agreed to by the insurer and may switch to another such professional once. When referred by the treating health care professional to another provider in a particular specialty, the employee may also change once to a different provider in such specialty. In cases of emergency or where the insurer or administrative judge agrees, the employee may seek treatment from additional providers. Where services are provided to employees under this section, the reasonable and necessary cost of such services shall be paid by the insurer.

On or before July first, nineteen hundred and ninety-three, the commissioner shall promulgate regulations regarding the provision of adequate and reasonable health care services. In doing so, he shall utilize the treatment guidelines developed and endorsed under the provisions of section thirteen. Any provision of health care services in material compliance with such regulations shall be presumed to be adequate and reasonable. Any material departure from said regulations shall be presumed to be either an inadequate or unreasonable provision of health care services.

An employee receiving benefits from the Workers' Compensation Trust Fund may be required to choose a treating physician from a health maintenance organization which has been chosen by the fund. In any instance in which the fund requires such a choice of an employee, the fund shall pay all co-payments, deductibles, or other costs required by the health maintenance organization for necessary and reasonable medical and hospital services under this chapter.

In any case where an administrative judge, the reviewing board, the office of education and vocational rehabilitation or the health care services board is of the opinion that the fitting of an employee eligible for compensation with an artificial eye or limb, or other mechanical appliance, will promote his restoration to or continue him in industry, it may be ordered that such employee be provided with such item, at the expense of the insurer. The provisions of this section shall be applicable so long as such services are necessary, notwithstanding the fact that maximum compensation under other sections of this chapter may have been received by the injured employee.

Any insurer may enter into a preferred provider arrangement in compliance with the requirements of chapter one hundred and seventy-six I of the General Laws and the regulations thereunder. Notwithstanding any other provision of this chapter, if an insurer enters into a preferred provider arrangement for health care services required under this chapter, those employees who are subject to the arrangement shall receive such care in the manner prescribed by the arrangement; provided, however, that a worker may receive immediate emergency treatment from a health care provider who is not a member of the managed care organization, and the insurer shall pay the reasonable and necessary costs of such treatment. Notwithstanding the provisions of this section, if an employee requests the services of a health care provider licensed or certified under the provisions of chapter one hundred and twelve and such specialty is not represented within the preferred provider organization with whom the employer has contracted, and the employee utilizes the services of such provider, the insurer or preferred provider organization shall pay the reasonable and necessary costs of such service. Said employee shall be allowed to choose any such health care provider.

Any insurer, with the written consent of the insured employer may, except as provided by the terms of a collective bargaining agreement, if any, approved under this chapter enter into a preferred provider arrangement for the employees of such employers in compliance with the requirements of chapter one hundred and seventy-six I and the regulations thereunder. If an insurer enters into a preferred provider arrangement for health care services required under this chapter, those employees who are subject to the arrangement shall receive such care in the manner prescribed by the arrangement consistent with this section.

Notwithstanding the provisions of this section if an employee requests, for his first scheduled appointment, the services of a health care provider licensed or certified under the provisions of chapter one hundred twelve and the specialty of said health care provider is not represented within the preferred provider organization with which the employer has contracted, and the employee utilizes the services of such provider, the insurer or preferred provider organization shall pay the reasonable and necessary costs of such service as provided under this chapter. In no instance shall employees be required to make copayments or pay deductibles.