Lawmakers nationwide will continue to push for targeted managed care refinements this year, a Blue Cross & Blue Shield Assn. survey indicates.

"I think it's fairly safe to say that the tension will continue" between state lawmakers who favor managed care and those who do not, said Susan S. Laudicina, director-state services research in the BC/BS Assn.'s Washington office. She noted, however, that much of the broad anti-managed care sentiment of recent years is dissipating.

"Broad anti-managed care bills did not pass any state legislature in 1996," said Ms. Laudicina during a press briefing last week. Instead of seeking to enact sweeping any-willing-provider laws, state legislators followed a more targeted approach to give consumers more flexibility, she said. One of the more popular examples of this tactic are laws requiring insurers to pay for minimum maternity stays, she said.

This targeted approach will continue in 1997, according to the association's survey of its member Blues plans, said Ms. Laudicina.

Based on the survey, legislative efforts are expected to fall into two categories, she said. The first, which she termed "medical management mandates," includes such requirements as a minimum length of stay in hospitals for mastectomy patients, which is expected to be an issue in 27 states.

In addition, lawmakers in 21 states are expected to push for mental health benefits parity. Another mandated benefit likely to be entertained by 16 state legislatures includes requiring that insurers pay for "experimental" treatment, which Ms. Laudicina said often is loosely defined.

Sixteen legislatures also are expected to deal with a bill that would require managed care programs to provide coverage for emergency room visits.

Ms. Laudicina called the second category "special-interest legislation" for providers. For example, the surveyed Blues plans anticipate that legislatures in 27 states will push for direct access, in which plan participants can visit certain providers without first obtaining gatekeeper approval, and other measures that run counter to managed care, she pointed out.

Lawmakers in at least four states are expected to seek enactment of legislation that will ban health plans from prohibiting providers from talking about medical treatment options with patients.

Another issue likely to emerge in state legislatures is how best to comply with the Health Insurance Portability and Accountability Act of 1996, also known as the Kassebaum-Kennedy Act.

Ms. Laudicina said most states will have to modify their existing health insurance market reforms, if only slightly, to comply with the act. The law, among other things, imposed portability requirements on employer-funded plans, including major restrictions on pre-existing medical condition exclusions; set federal requirements for plans offering coverage in large and small group markets; and gave states flexibility to opt out of the law's requirements by setting acceptable mechanisms of their own.

As a result, some states may enact legislation to create medical high-risk pools for certain people, she said. She added, though, that some Blues plan respondents fear the opt-out legislation could become a vehicle for more benefit mandates by the states.