PHARMACIST STEVE

Managed Care State Laws and Regulations, Including Consumer and Provider Protections

http://www.ncsl.org/research/health/managed-care-state-laws.aspx#i

This is a little complex, but states laws vary as to what managed care, health insurance and the like are required to provide or prohibited from denying services.  Might be of benefit when pts are appealing change of existing meds/therapy… and or denial of care.

Updated: May 2010; material added September 2011 Archive Report:  This summary compilation of state laws and polices was originally compiled and published 2000, with regular updates and additions through 2005.  Because states enacted far fewer changes in this area since 2005, this report is no longer maintained on a regular basis.  It remains an accurate historical “panaramic” view of the range of state-specific initiatives in an era where there was relatively little federal law. The Affordable Care Act – the 2010 federal law substantially adds to the regutory requirements in some of the areas covered in this report.  See NCSL’s latest (2010-2011) reports and descriptions online at the NCSL Health Reform website, http://www.ncsl.org/Default.aspx?TabID=160&tabs=831,139,1156#1156

 

More than 170 million Americans receive health care coverage or benefits through some type of “managed care” setting.1  By 2007 about 20 percent of these services are directly provided by a health maintenance organization (HMO), while the majority are served through other managed arrangements, 60 percent in Preferred Provider Organizations (PPO) and 13 percent in Point of Service (POS) plans.

Nearly all states have passed “patient protection” or consumer-oriented laws and/or regulations.  State legislation and resulting enacted laws were an intense focus from 1992 through 2002, with dozens of measures enacted yearly, amidst major media attention, anecdotal stories of patients denied treatment, and several major lawsuits. The U.S. Congress has not enacted comparable managed care consumer legislation, although different plans passed the Senate and/or House between 1999-2002.   This activity has dropped off dramatically since 2002, in part because so many states already had laws in place.  The Health Policy Tracking Service summarized this change as “state legislatures and regulatory agencies, consumers and managed care entities have reached a reasonable operational balance.” 2  Since 2001 HMO enrollment has declined in many areas, but the enacted laws generally remain in place and in force. 

The details and the extent of these state laws vary considerably, but they remain in force as a mechanism for regulating HMOs and other forms of managed care organizations. The actual extent of these laws vary and is not detailed in this report.

STATE ROLES LIMITED BY ERISA:

State health insurance laws only apply to about 45% of health policies – those “fully insured plans” in which mostly individuals and small and medium sized businesses and organizations pay premiums. Only federal ERISA law applies to the 55% “self-insured health insurance policies.”  The U.S. Department of Labor oversees and enforces ERISA requirements, which are generally less extensive than the state requirements noted below.  Many insurers offer and administer both types of plans.  Medicaid managed care plans are administered through state law but consumer and provider protections may be regulated separately from the statutes cited in this report.  See statute language for details.
    (Source: EBRI, September 2007)

Access to Services – Table 1 Access to Services – Table 2 Appeals and Remedies – Table 3 Provider Flexibility and Report Cards – Table 4 Mandate Examples – Table 5 Comprehensive Consumer Rights Statutes with citations – Table 6 2005-07 Managed Care Laws – Table 7

.

Also see Managed Care Overview, an NCSL compendium of reports and documents, updated 2006.

Table I ~ Access to Services

• Comprehensive Consumer Rights Laws
• Any Willing Provider –
• Continuity of Care –
• Direct Access to OB/GYN –
• Direct Access to other health professionals.
• Specialist as Primary Care Provider –

– These multi-purpose laws, often 20 to 50 pages in length, generally are designed to define and protect the rights of health care consumers enrolled in managed care. Often they are termed “patient protection” or “consumer rights” laws. Statute citations and links to full text are listed below, in

Table #6

Numerous states require that managed care organizations contract with any provider (from physicians and hospitals to pharmacists and chiropractors) that is willing to meet the terms of the contract.

Update:

An April 2003 U.S. Supreme Court decision affirmed the Kentucky law, and the validity of such state regulation more generally. A number of states require managed care plans to provide current and new enrollees the opportunity to continue to receive care and services for a period of time with a provider that has been terminated or dis-enrolled from the plan. Many states now allow women to see an obstetrician or gynecologist without first getting permission or a referral from a primary care provider. Some states also afford women the ability to designate their OB/GYN as their primary care provider. For people with a single chronic health problem, the usual HMO procedure of calling a primary care provider first for a referral can be frustrating and unproductive. A number of states now allow an enrollee to select a specialist (such as a neurologist, a mental health provider or a cancer specialist) to be their main provider.

% Key : Numbers indicate year of law enactment |  blue = web link |  reg [italics] = regulation only

 Index by First Letter of State A C D F G H I K L M N O P R S T U V W

State	Comp. Consumer Rights	Any Willing Provider	Continuity of Care	Direct Access, OB/GYN	Direct Access, other	Specialist as PCP
Alabama	99	<97	.	96	01	.
Alaska	98, 00		00		98
Am. Samoa	.	.	.	.	.	.
Arizona	<97, 00	.	00	.	00	.
Arkansas	97	05	97	97	<97	.
California	94, 95, 99	.	98	<97, 98	.	.
Colorado	97	.	97	97, 98	.	.
Connecticut	97	<97	.	97	95, 00	.
Delaware	98	<97	98	97	.	.
Dist. of Columbia	98	.	98	98	98	.
Florida	97, 00	repeal 00	97, 99	97	97
Georgia	96, 99, 99	<97		96	95
Hawaii	98
Idaho	97	94		96
Illinois	99, 99	<97, 99	99	96
Indiana	98	<97	98	97, 98	98	98
Iowa	99		99
Kansas	97		96	01	98
Kentucky	98, 00	94, 98, 00, 02	00	00
Louisiana	97		95	97
Maine	96, 00		00	95, 97	95?
Maryland	95		96	94	99	99
Massachusetts	00	94, 99	00	00	00
Michigan			01		99?
Minnesota	<97, 97	94	97	97
Mississippi	95	94		95
Missouri	97		97	97	01?
Montana	97			97	97?
Nebraska	98			97
Nevada	97			97
New Hampshire	97	<97	97	97, 98	00?
New Jersey	97	93	97	97		97
New Mexico	98			97		98
New York	96		<97	97	<97	97
North Carolina	01	<97, 01	01	97		01
North Dakota	99	<97
Ohio	97, 99			99
Oklahoma	97, 99		99		99
Oregon	95, 97, 01		01, 05	97
Pennsylvania	98		98	98		98
Puerto Rico
Rhode Island	96		97	97
South Carolina	98	<97	98	98
South Dakota	99, 03	90 Rx	84, 00, 01
Tennessee	98, 00	<97, 98	98	97, 98		98
Texas	96, 97, 97	95	<97, 97	97	<97	97
U.S. Virgin Is.
Utah				97, 98
Vermont	96	.	97	97	.	.
Virginia	95, 98, 99, 99		96, 99	96	97,99,00	99-00
Washington	96, 00	.	00	95	00	.
West Virginia	01	.	01	98, 01	.	.
Wisconsin	98	<97	98	99	.	.
Wyoming	.	<97	.	.	.	.

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Table II ~ Access to Services, Part 2

• Standing Referrals to Specialist –
• Emergency Care Coverage –
• Emergency Prudent Lay Person –
• Emergency Room coverage.
• Freedom of Choice –
• Ombudsman/Consumer Assistance –

Many states call for health plans to institute procedures that provide an enrollee that requires specialized medical care over a prolonged period of time to receive a standing referral to a specialist. This is generally for people with a chronic, degenerative, disabling or life-threatening disease. Numerous states require reimbursement for emergency care services. This includes screening and stabilization. Many state laws specify automatic coverage for emergency medical conditions “of sufficient severity, including severe pain, that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of medical attention to result in placing the person’s health in jeopardy.” Managed care organizations can not discount the price for their enrollees by reducing the selection of providers. These programs are state-funded, independent offices that act directly on behalf of a patient unable to get needed medical care or other services.

First Letter of State A C D F G H I K L M N O P R S T U V W

State	Standing Ref. To Specialist	Emergency Care Coverage	Emergency Prudent Lay Person	Emergency Room	Freedom of Choice	Ombdsm./ Consumer Asst.
Alabama	99	99	99		<97
Alaska					98
American Samoa
Arizona	00	96	00
Arkansas		<97	<97
California	98	94				<97, 99
Colorado	99		<97	<97		98
Connecticut		97	<97		98	99
Delaware	01	98	98		<97
District of Columbia	98	98	98
Florida	97	96			<97	96, 98, 00
Georgia		96	<97	<97	<97	99
Guam
Hawaii	99	98, 99	97
Idaho		97	<97		<97
Illinois	99		99			99
Indiana		<97, 98	98
Iowa			99		<97
Kansas	<97	97	<97
Kentucky	00	98, 00	98, 00		96	98
Louisiana		<97, 99	<97, 99		<97
Maine	00	00	<97, 00			98
Maryland	99, 00	96, 98,	<97		<97	99
Massachusetts	00		00			98, 00
Michigan			<97			<97
Minnesota	<97	97	<97	<97		<97, 98
Mississippi			99		<97
Missouri	<97		<97	<97
Montana		97			<97; 01
Nebraska		98	<97
Nevada		97, 99	<97
New Hampshire		97
New Jersey		97			93	00
New Mexico	<97; 97	97, 98	<97	<97
New York	96	96	<97
North Carolina	99, 01	97	<97		<97	01
North Dakota			99		<97
Ohio	<97	97	<97	<97
Oklahoma	99	97	00		<97
Oregon	01	01	<97			<97
Pennsylvania	98	96, 98	98	98
Puerto Rico
Rhode Island						99
South Carolina	98		98		98
South Dakota		99	99	99, 03	90 Rx
Tennessee	98	97	<97		<97, 98	<97
Texas		97	<97		<97	99
U.S. Virgin Islands
Utah	00		00			99
Vermont	<97		<97			98
Virginia	99, 00	<97, 97	<97, 00	<97	<97	99
Washington	00		<97
West Virginia	01	96	98, 00		01
Wisconsin	98		<97, 98			<97
Wyoming

 

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Table 3 ~ Appeals and Remedies

• Independent/External Review of denials
•  Many states now require an independent or “external appeal” panel to evaluate the validity of denied care. Once opposed as too costly by the managed care industry, this idea now is embraced as a “reasonable” alternative to court suits. 
• >  An Update on State External Review Programs, 2006 This report by AHIP provides an analysis of publicly available data from state external review programs operating in 2006. Published 7/9/2008.
• Insurer Liability –These state provisions held health maintenance organizations liable for health treatment decisions. NOTE: A landmark U.S. Supreme Court decision in July 2004 ruled unanimously that patients cannot sue their HMO under state laws for failing to pay for doctor recommended care.  Experts describe the decision as ruling that federal ERISA law “completely pre-empted such lawsuits brought in state court.”  The listings below are retained for legislative history, but portions of the statutes may not be in effect. Offers people the ability to receive services from an out-of-plan provider given that they are willing to pay higher out-of-pocket costs. Managed care organizations might offer this type of plan to eliminate the use of closed-panel HMOs.
• Liability: Ban on “hold harmless” clauses in Provider Contracts
• Liability, Financial: Enrollee
• Point of Service –
• Right to a second medical or surgical opinion – 9 states formally mandate the option to obtain a second opinion, with costs covered by insurance.   These states are CA, MD, MN, MO, NJ, NY, RI, WV & WI. (not listed in the Table below) 

First Letter of State A C D F G H I K L M N O P R S T U V W

State	Ind./External Review of Denials	Insurer Liability	Liability: Provider Contracts	Liability, Financial: Enrollee	Point of Service
Alabama
Alaska	00				98, 00
American Samoa
Arizona	<97, 00	00
Arkansas	97, 05			97, 01	99
California	96, 99	99	99
Colorado	<97, 99, 05			97
Connecticut	97, 05		97	97
Delaware	98, 01			98
District of Columbia	98
Florida	<97, 00
Georgia	99	99	99		96
Guam
Hawaii	98, 00
Idaho					97
Illinois	99		99		00
Indiana	99, 01		97	98	98
Iowa	99, 01				97
Kansas	99			97
Kentucky	00
Louisiana	99	99	97	97
Maine	00	00	97, 00
Maryland	98, 01		<97		<97
Massachusetts	00		00		00
Michigan	<97, 00
Minnesota	99				<97
Mississippi
Missouri	<97	97	97
Montana	99		99		97
Nebraska				98
Nevada	01
New Hampshire	00, 05		93, 97
New Jersey	<97, 01	01			97
New Mexico	<97	98
New York	98		96		95
North Carolina	97, 01, 05	01
North Dakota	05		97	99
Ohio	<97, 99			97
Oklahoma	99	00	00	97	97
Oregon	01	01	<97		95
Pennsylvania	98
Puerto Rico
Rhode Island	<97		96, 99
South Carolina	00		98		98
South Dakota	99, 03		99	99
Tennessee	97, 98, 99		97	98	98
Texas	97	97	97, 99	99	97, 99
U.S. Virgin Islands
Utah	00
Vermont	<97, 98		97
Virginia	99		98,	97	98
Washington	00, 01	00	00		00
West Virginia	01	01
Wisconsin	00				99?
Wyoming
State	Ind./Ext. Review of Denials	Insurer Liability	Liability: Provider Contracts	Liability, Financial: Enrollee	Point of Service

 

Table 4 ~ Provider Flexibility and Report Cards

• Bans on Financial Incentives –
• Ban on Gag Clauses –
• Report Cards –
• Medical Director Requirements –
• Hospital Stay after Childbirth –
• Ban on “All Products” Clauses – Some contracts between providers and managed care companies require the provider to contract for all products that are offered by the managed care entity.  Several states have banned the use of such requirements as an unfair trade practice. (updated 2006)

Many states prohibit a managed care plan from rewarding doctors for performing a less costly procedure or prescribing a less costly drug. Most states have laws prohibiting any agreement that limits doctors’ ability to inform patients of treatment options, especially if some choices may cost the insurer more. A 1997 federal law now bans gag clauses for Medicaid and Medicare managed care. In an effort to assist consumers in choosing a plan, several states now require publication of an evaluation booklet or, “report card” to report on the performance of a managed care organization. Also see

NCSL Report

.

 

Some managed care organizations’ chief officers have business degrees rather than medical credentials. During the past few years, several states have established specific qualifications and responsibilities for HMO medical directors; most require a current in-state medical license. Many states require reimbursement for (typically) at least a 48-hour maternity stay. A federal law requiring coverage for a 48-hour stay took effect in January 1998.

First Letter of State A C D F G H I K L M N O P R S T U V W

State	Ban on Financial Incentives	Ban on Gag Clauses	Report Cards	Medical Director Requirements	Hospital Stay after Childbirth	Ban All Products Clauses
Alabama				99 reg	96
Alaska	98, 00	98, 00			96	01
Am. Samoa
Arizona	00	97		00	97
Arkansas		97		X reg	97
California	96	96	99	99	97
Colorado		96	99	Reg	98
Connecticut		97	95		96 [’07]
Delaware	98	96		99	97
Dist. of Columbia		98
Florida	96	97	97	97	96
Georgia	97, 99	96, 99			01
Guam
Hawaii		98		99
Idaho	97	97			96
Illinois	97	99		99	96
Indiana		96		98, 00	96
Iowa		97, 99	99		96
Kansas	97	97	99		96
Kentucky		98		X	98	01
Louisiana	97, 99	97	99	99	97
Maine	00	96			95, 95
Maryland	96	96	98	98	X	00 H, S
Massachusetts	00	<97, 00	00	00	X
Michigan		96, 97	00
Minnesota	97	97, 00	74	01	96	00
Mississippi
Missouri	97	97	99	00	96
Montana	97	97		01	97
Nebraska	97, 98	97
Nevada	97, 99	97		97	97	98
New Hampshire	00	96		00	96
New Jersey	97	97, 97	98	97	95
New Mexico	97, 98	97, 98	94, 99		96
New York		96	98	X	96
North Carolina	01			99	97
North Dakota	99	97		99?	X
Ohio	97	97			96
Oklahoma		97	98	X	96
Oregon		97	<97, 99		95
Pennsylvania	98	96			96
Puerto Rico
Rhode Island	96	96, 97	<97, 99	X	96
South Carolina		98		99	76
South Dakota	99	99		99	96
Tennessee		96	99		96
Texas	97, 99	97	95	X	97
U.S. Virgin Islands
Utah		97	98, 99		01
Vermont	97	96	99	00
Virginia		96	99	00	96, 01	00
Washington		96, 00	99	00	96
West Virginia	97, 01	97			97
Wisconsin		75, 98	99	97
Wyoming		97
State	Ban on Financial Incentives	Ban on Gag Clauses	Report Cards	Medical Director Requirements	Hospital Stay after Childbirth	Ban All Products Clauses

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Table 5 ~ Mandates for Insurance Coverage (Examples)

These mandates are just four coverage examples of the 40+ types of mandated requirements enacted across all 50 states. A more detailed list, published by the Council for Affordable Health Insurance is available here: 50- state mandate information, 2009 update.  (a pdf format document).

• Diabetes –
• Inpatient Care after Mastectomy –
• Post-Mastectomy Breast Reconstruction – Coverage for reconstructive surgery of cancerous breast and/or unaffected breast in order to achieve symetry.  “Yes” indicates that the reconstruction is covered IF mastectomy is also covered.
• Off-label Prescription Drug Use –

require coverage of

 

pharmaceuticals, equipment, supplies and sometimes education for at-home treatment. Additional details at

Diabetes mandates

web page. Coverage for a minimum number of hours in an inpatient hospital is mandated after a mastectomy or lymph node dissection. For specific uses, like treating cancer or other life-threatening diseases, all prescription drugs are to be covered. This includes drugs that are not FDA approved.

First Letter of State A C D F G H I K L M N O P R S T U V W

State	Diabetes Supplies	Inpatient Care after Mastectomy	Post-Mastectomy Breast Reconstruction	Off-label Prescription Drug Use
Alabama				<97
Alaska	00		00
Am. Samoa
Arizona	98, 00		<97, 99	00
Arkansas	97	97	<97	<97
California	<97, 99	98	98	<97
Colorado	98
Connecticut	97	97	<97	<97
Delaware	00		yes	yes
Dist. of Columbia	00		yes
Florida	95	97	<97	<97
Georgia	98	99	yes	<97
Guam
Hawaii	00
Idaho			00
Illinois	98	97	<97	<97
Indiana	97		<97	<97
Iowa	84, 99		yes
Kansas	98		<97	99
Kentucky	98	98	98	98
Louisiana	97		<97, 99	97
Maine	96	97	<97	98
Maryland	97	99	<97	<97
Massachusetts	<97, 00			<97
Michigan	00		<97	<97
Minnesota	94, 97		<97	98
Mississippi	98		yes	97
Missouri	97		<97	97
Montana	01	97	<97
Nebraska	99		00	yes
Nevada	97		<97	99
New Hampshire	97		<97	99
New Jersey	96	97	<97	<97
New Mexico	97	97	yes	97
New York	93	97	<97	<97
North Carolina	97	97	<97	<97, 01
North Dakota			yes	97
Ohio		01	yes	<97
Oklahoma	96	97	<97	<97
Oregon	87, 01		yes	97
Pennsylvania	98	97	<97	yes
Puerto Rico
Rhode Island	96	97	<97	<97
South Carolina	99	98	<97	<97
South Dakota	99, 00		yes	00
Tennessee	97		<97	97
Texas	97, 99	97	<97, 99	99
U.S. Virgin Islands
Utah	00		00
Vermont	97			yes
Virginia	98, 99, 00	98, 98	98	<97, 97
Washington	97		<97	<97
West Virginia	96		<97
Wisconsin	87		yes
Wyoming	01

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Table 6 ~ Comprehensive Consumer Rights Statute Citations

First Letter of State A C D F G H I K L M N O P R S T U V W

STATUTES
Alabama	1999-2000 Regulations
Alaska	1998 law: SB 197 2000 law: HB 211
Arizona	<1997 law 2000 law: HB 2600
Arkansas	1995, 1997 law: AR Code §23-99-201 ; AR Code §23-99-401 et seq. 2005 law: SB 191
California	1994 law: SB 1832 1995 law: AB 1152 1995 law: AB 1266
Colorado	1997 law: HB 1122; Colo. Rev. Stat. §10-16-702 et seq.
Connecticut	1997 Conn. Acts, P.A.97-99 HB6883    [link 07] 2003: Conn Acts P.A. 03-169 [effective 2004]
Delaware	Del. Code Ann. tit. 16, § 9110 (1998)  [repealed] Del. Code Ann tit. 18 Insurance  § 6401 et seq.
District of Columbia	1998 law
Florida	1997 law: HB 297 2000 law: HB 2339
Georgia	1996 law: HB 1338 1999 law: SB 210 1999 law: HB 732
Hawaii	1998 law: SB 2297
Idaho	1997 law: SB 1150
Illinois	1999 law: SB 251 1999 law: (dental only) SB 721
Indiana	1998 law: SB 364
Iowa	1999 law: SF 276
Kansas	1997 law: SB 204
Kentucky	1998 law: HB 315 2000 law: HB 390
Louisiana	1997 law: HB 2228
Maine	1996 law: S 769 2000 law: Chapter 742 of 2000 LD 543
Maryland	1995 law: HB 724 and SB 499
Massachusetts	Mass. Gen. Laws Ann. ch. 141, § 16D (2000) H 4525            [link 07]
Michigan	n/a
Minnesota	<1997  Minn. Stat. Ann. Sections 62J.695 to 62J.76, cited as the “Patient Protection Act.”  (1997) SF 960
Mississippi	1995 law: SB2669 Certification standards only
Missouri	1997 law:  MO Stat. 354.400 et. seq.   HB 335
Montana	1997 law: SB 365
Nebraska	1998 law: LB 1162
Nevada	1997 law: AB 156
New Hampshire	1997 law: SB 178
New Jersey	1997 law: SB 269
New Mexico	1998 law: HB 361
New York	1996 law: SB 7553 (NY Ins. Sec. 48)
North Carolina	1997 Regulations; 2001 law: S 199 (Session Law 2001-446; effective March 1 & July 1, 2002)     [link ’08]
North Dakota	1999 law: SB 2400
Ohio	1997 law: SB 67 HB 361
Oklahoma	1997 law: HB 1416 [link ’08] 1999 law: HB 1681 [link ’08]
Oregon	1995 law: SB 979  1997 law: SB 21 2001 law: HB 3040
Pennsylvania	1998 law: SB 91
Rhode Island	1996 law: RI Gen. Laws § 23-17.13-1 et seq.
South Carolina	1998 law: SB 310
South Dakota	1999, 2000, 2003 laws: SD Chapter 58-17C                   [link ’07]
Tennessee	1998 law: HB 2949
Texas	1996 Regulation Tex. Insurance Code Ann. § 3.70-3C (1997) SB383 Tex. Insurance Code Ann. § 1.35A (1997) SB385
Utah	n/a
Vermont	1996 law: S.345 Rule 10.000 Quality Assurance Standards and Consumer Protections for Managed Care Plans
Virginia	1995 law: HB 1973 (Chapter 745) 1996 law: HB 1393 (Chapter 776) 1998 law: SB 712 (Chapter 891) § 32.1-137.1. 1999 law: HB 871 (Chapter 649) 1999 law: SB1235
Washington	1996 law: SB 6392 2000 law: SB 6199
West Virginia	2001 law: HB 2216
Wisconsin	1998 law: AB 768
Wyoming	n/a

2005-07 Managed Care Laws

Although more than 98 percent of state Managed Care Laws were enacted prior to 2003, several states did passed laws in 2005, mostly amending or expanding earlier laws.  A 2007 CT law passed in May.   These are 10 of the more substantive state measures.

STATE	2005-07 MANAGED CARE LAWS 2
AR	SB 190, SB 191  Patient Protection Act. Includes broad “any willing provider” (AWP) provisions, and a right to sue for violations, including of AWP sections.
CO	SB 37 expands external review by requiring second-level internals appeals of denied benefits, by a 3-member panel, with 2 independent experts.
CT	HB 7000 provides that the Managed Care Ombudsman will work to “foster communication between mental health professionals and providers.” SB 1002 expands independent review by requiring that adverse rulings must include the “principal reasons for the the determination” and terms for further appeal to the state commissioner of insurance. SB 1297 creates a fine for failure to provide notice of the resolution of a complaint. H 7055 of 2007: establishes a statutory definition of medical necessity or medically necessary for health insurance coverage to ensure consistency throughout health insurance policies; creates a presumption that a treatment is medically necessary.
IN	SB 254 allows HMOs to provide selected documents in electronic or paper form.
NH	HB 737 clarifies that a covered beneficiary who uses a voluntary internal appeal or review may also request an external review. SB 77 provides that providers are entitled to a complete copy of any proposed contract and 60-day notice for any material change in fee schedules.
NC	SB 74 expands existing managed care laws to clarify that they apply to individual insurance plans as well as group plans.  Restricts external review to normal business hours.
OR	HB 3465 expanded “continuity of care” provisions.
RI	SB 774 change the total minimum net worth required for an HMO Certificate of Authority.
TX	SB 1284 provides that mergers between two HMOs make them subject to preexisting insurance law.
WV	SB 425 provides for grievance procedures and permits health status as an underwriting condition; also includes HMOs to risk-based capital requirements and incorporation standards.

Notes:

Italics = Regulations, not statute
1 – America’s Health Insurance Plans, 2005 Report
2 – “Managed Care” Issue Brief by Thomson West/Health Policy Tracking Service, 12/31/2005

Compiled by Richard Cauchi, NCSL Health Program, Denver, Colorado.   This is a preliminary edition of NCSL research, subject to additional edit and design work prior to final publication.

Filed under: General Problems