MANAGED CARE TARGETED FOR RESTRICTIONS, MANDATES REFORMS OF MASTECTOMY COVERAGE, EMERGENCY CARE (PART FOUR OF FIVE)

The Arizona Legislature passed and Gov. Fife Symington signed several measures designed to protect the rights of health care recipients. All of those laws become effective July 21.

Provisions of the measures:

Prohibit managed care plans from barring providers from fully disclosing to patients their medical needs, treatment options and benefits. The legislation also requires utilization review agents and insurers that use their services to adopt written UR plans. And, it establishes procedures for appealing UR decisions.

Prohibit health, life, disability and long-term care insurers from requiring genetic testing as a condition of coverage.

Require health care providers to obtain verbal and written consent from their patients before they can practice telemedicine.

Arkansas Gov. Mike Huckabee signed several health care bills during the legislative session, which ended April 17. The measures:

Require health insurers to cover the diagnosis and treatment of mental illnesses and developmental disorders.

Require insurers to cover diabetes self-management training and certain equipment, supplies and services for treatment of diabetes.

Set minimum maternity hospital stay coverage requirements of 48 hours after a normal vaginal delivery and 96 hours for a Caesarean section. In addition, the legislation sets minimum hospital stay coverage of 48 hours for mastectomies, allows women in managed care plans that require a primary care physician to also choose an obstetrician/gynecologist and go directly to the Ob/Gyn without a referral, and prohibits the use of gag clauses.

Oklahoma Gov. Frank Keating signed a managed care patient-protection measure that, among other things, calls for employers to offer a point-of-service plan.

The law requires employers that previously had offered only a health maintenance organization health plan to offer a POS plan as well. The law, which applies to employers with 50 or more employees, became effective immediately.

The chief intent of the law is to direct the State Board of Health to develop rules to protect managed care plan patients. For example, the law calls for rules that:

Prohibit physician gag orders.

Require plans to provide clear explanations of benefits.

Prohibit plans from excluding from their networks physicians who have practices with a substantial number of patients requiring high-cost care.

The Texas Legislature passed a sweeping package of reforms, including legislation that allows managed care patients to sue their HMOs. One of the first of its kind, the law exposes HMOs to new civil liability for denying or delaying treatment. Similar legislation is pending in Missouri and New York.

Gov. George W. Bush allowed the bill to become law without his signature. It takes effect Sept. 1. The law requires that, before suing, a patient must appeal the case to an independent physician reviewer selected by the Texas Department of Insurance. The reviewer will determine whether the HMO should have paid for treatment.

Among reforms Gov. Bush has signed are measures that:

Amend the Texas HMO Act to transfer oversight functions to the Texas Department of Insurance from the Texas Department of Health, establish complaints and appeals procedures and require disclosure of information to patients.

The law also requires referrals to non-network providers for medically necessary covered services not available through network providers and directs the Office of Public Insurance Counsel to produce HMO report cards for consumers.

Establish standard utilization review procedures and require that personnel performing UR functions must be licensed physicians, nurses or physician assistants.

Allow women direct access to their obstetrician/gynecologists without a referral from a primary care physician.

Require HMOs to cover breast reconstruction after mastectomies.

Mandate coverage for minimum hospital stays of 48 hours after childbirth.

(continued in part 5).