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

Managed care laws enacted in New Mexico during the 1997 legislative session included the Health Insurance Portability Act, which brings the state into compliance with federal law that allows for the portability of health coverage when a person changes jobs, according to Blue Cross & Blue Shield of New Mexico. The law is effective immediately.

In addition, the Provider Service Network Act, among other provisions, creates a guaranty fund association for provider service networks in case of insolvency.

The Minimum Hospital Stay for Mastectomy law, effective July 1, requires hospital coverage to include 48 hours of inpatient coverage for mastectomy and 24-hour inpatient coverage after a lymph node dissection for treatment of breast cancer.

Among the health care-related legislation that was vetoed was the Patient Protection Act, which would have given the state Department of Insurance authority to implement managed care regulations.

Bills that were killed included an any-willing-provider proposal that would have required managed care plans to accept any provider willing to meet the requirements to be a primary care physician. Also killed was a bill that would have required managed care plans to provide unlimited mental health services.

Colorado lawmakers passed legislation that, among other things, would bring the state into compliance with the federal law creating health care benefit portability.

Two companion measures concerned treatment and coverage of "intractable pain" or chronic, incurable pain. The bills would allow plan physicians to prescribe treatment for such conditions and require indemnity plan underwriters to stipulate in contracts beginning Jan. 1, 1998, whether there is coverage for such treatment. Treatment could be provided by a primary care physician or by a pain management specialist.

A controversial section of Idaho's Managed Care Reform Act, which was approved by the 1996 Legislature and signed into law in March, requires managed care organizations to offer a point-of-service option to patients. The law takes effect July 1 and allows enrollees to choose non-network providers for a higher copayment or deductible. Other provisions include benefit disclosure requirements, utilization review protections, grievance procedures and provider contract provisions.

Montana enacted several health care-related bills, including legislation that:

Requires insurers to cover hospital stays of any duration, as determined by a doctor and patient, and mandates that patients receive written material about their medical conditions and procedures.

Combines two National Assn. of Insurance Commissioners model acts on network adequacy and quality assurance. The law allows Montana to set minimum standards based on the Health Plan Employer Data & Information Set standards that all managed care companies must meet. It also prohibits managed care companies from requiring prior authorization for emergency care but allows them to decline to reimburse emergency care if it is determined that the care was not really an emergency. The law is effective in phases beginning Oct. 1, 1999.

Mandates maternity hospital stay coverage of at least 48 hours for a vaginal delivery and 96 hours for a Caesarean delivery.

Requires HMOs to offer a point-of-service option, though employers may decide whether to buy that option for its employees.

Allows an obstetrician/gynecologist to be designated as a primary care physician and provides women direct access to an Ob/Gyn.

Prohibits underwriting discrimination against domestic abuse victims.

In Nevada, the Legislature approved and Gov. Bob Miller signed comprehensive managed care legislation that will take effect Oct. 1. The legislation defines managed care and provides oversight for all managed care organizations as well as limits their ability to deny covered health services.

Among its provisions, the law also requires written policies and procedures for utilization review, prohibits managed care organizations from reprisals against physicians who act as advocates on behalf of patients and forbids financial inducements that limit medical services. The law also has provisions for emergency services in managed care plans and requires each managed care organization to develop a quality assurance program.

Managed care organizations also must file with the state and make available to the public financial reports as well as descriptions of any complaints that lead to legal proceedings. A complaint resolution procedure also is required.

Utah enacted legislation that prohibits the use of gag clauses in provider contracts. The law became effective in May.

The Wyoming Legislature passed a measure that requires the life and health insurance guaranty association to include coverage of policies sold by Blue Cross & Blue Shield organizations.

California lawmakers have launched an attack on managed care following the defeat of many similar measures at the ballot box last November (BI, Nov. 11, 1996; Oct. 14, 1996).

More than 60 bills have been introduced in both houses that, among other things, would prescribe coverage for hospital stays and limit HMO mergers.

Lawmakers are taking aim wherever they suspect California HMOs and other managed care plans are cutting costs at the expense of patient welfare.

But, some of these reforms may be misdirected given the change that has occurred in California health delivery over the past few years, suggested Alan Tomiyama, vp of public affairs for the California Assn. of Health Plans in Sacramento.

"The delivery system in California is vastly different today than it was in 1993, 1994 or even 1995," he said.

While in the past, health plans were blamed for dictating patient care to keep their costs low, "in 1997, hospitals and doctors are capitated," he explained.

As a result, much of the legislation directed at health plans and HMOs will have little or no effect on patient care, Mr. Tomiyama said. "All it's going to do is create more regulation and more paperwork," he said. "It just doesn't make any sense."

While it is unknown at this point how many of the bills Gov. Pete Wilson will sign, he has shown increased interest in health care regulation. His task force of consumer, health care and insurance experts is investigating how best to reform HMO regulation in the state.

Bills that have passed at least one house of the California Legislature include measures that would:

Compel a managed care network intending to dismiss a doctor to explain its decision and submit disputes to binding arbitration.

Require managed care organization authorities who make coverage decisions to be licensed physicians in California. The Department of Corporations, which has regulated HMOs in California since 1975, has come under sharp criticism lately as too lax.

Transfer state regulation of managed care organizations to other state agencies, or to what would be a newly created Department of Health Care Oversight, from the Department of Corporations.

Require coverage for certain minimum hospital stays for patients who undergo breast cancer surgery or a lymph node exam.

Mandate maternity hospital stay coverage of 48 hours after a normal vaginal delivery and 96 hours after a Caesarean section.

Require prior state approval of HMO mergers, in an attempt to curb monopolies and encourage competition.

Oregon Gov. John Kitzhaber signed legislation that would require health insurers to disclose a broad variety of information to plan enrollees. The law also bars insurers from penalizing providers over their communications with plan enrollees, gives enrollees a two-level grievance review process and requires insurers to provide enrollees detailed information on treatment policies for particular conditions.

In addition, the legislation requires insurers to reveal financial risk-sharing arrangements between the insurers and health care providers.

Other health care-related measures have been introduced but still are pending in the Oregon Legislature. They include bills that would:

Allow school districts to self-insure their health care benefits.

Require insurers to allow any pharmacy willing to abide by the insurer's reimbursement contract to fill prescriptions.

Mandate that health plans reimburse enrollees for services rendered by marriage and family counselors.

Washington Gov. Gary Locke vetoed legislation approved by lawmakers that would have blunted several health care reforms created in 1994. Legislators approved a bill that would repeal requirements that insurers offer coverage to all applicants regardless of their medical history, limit waiting periods to no longer than three months and restrict insurers' ability to cancel coverage.

No significant health care legislation was enacted this year in Alaska or Hawaii.