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Member, Beacon International Group, Ltd.
TRENTON, N.J.-New HMO regulations, including an "HMO consumer bill of rights," take effect March 15 in New Jersey.
Among the patient rights outlined in the regulations:
Only doctors can decide to deny or limit coverage.
Consumers must have a choice of specialists.
'"Gag rules" that prevent physicians from discussing non-covered treatments with patients will be eliminated.
HMOs are required to disclose to patients their payment arrangements with doctors.
Consumers must have the right to appeal a decision to deny or limit coverage, first within the HMO and then through an independent organization.
The independent utilization review organization will issue non-binding recommendations on coverage appeals, and the HMOs must report to the state health department whether they will accept or reject the recommendations.
The health commissioner's office will also compile a yearly report card of each HMO in the state and publish the results of enrollee satisfaction surveys. Every three years, each HMO will also undergo a quality review by an independent organization. That report will be reviewed by the state.
The regulations are the result of a two-year effort involving the state's Department of Health and a committee of HMOs, physicians and consumers. The growth of HMO enrollment in the state to more than 2 million people prompted Health Commissioner Len Fishman to rewrite the 1974 regulations and add consumer protections.
"These are the most progressive, consumer-oriented regulations in the country," Mr. Fishman said in a statement.