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Connecticut Gov. John Rowland this month signed sweeping managed care legislation. The new law, which the Legislature passed in May, establishes an external appeals process in which the insurance commissioner or an independent panel of health care experts appointed by the commissioner can rule on coverage disputes. The law also requires managed care organizations to set up internal complaint review procedures; bars gag clauses in which physicians are prohibited from discussing non-covered treatment options with patients; and requires the commissioner to develop an annual "consumer report card" on managed care organizations starting in 1999.
Maine Gov. Angus S. King Jr. signed several health care-related bills during the legislative session that ended June 2.
The new laws:
Require health care payers to calculate copayments or deductibles based on actual costs rather than percentages.
State that a beneficiary has no duty to pay back a health insurer for benefits received until the beneficiary has received full payment from other sources. In addition, health insurers recovering payments must reduce amounts recoverable to reflect beneficiaries' attorneys' fees and costs.
Require HMOs that offer mental health services to cover services performed by a counseling professional.
Prohibit removing high-risk participants from group health care coverage and forcing them to buy individual coverage.
Mandate coverage for 48 hours of inpatient care for a mastectomy and 24 hours of inpatient care for a axillary lymph node dissection for treatment of breast cancer.
In Massachusetts, legislation that proposes new regulations is pending in the House's Health and Insurance committees. Among its many provisions, the bill would require health insurers to disclose more information so the state can issue report cards on providers, and it adopts a reasonable lay person provision for the coverage of emergency services.
The New Hampshire Legislature passed and Gov. Jeanne Shaheen signed a bill that will give the Department of Insurance power to set rules on: managed care networks' procedures in resolving complaints about coverage denials; utilization review processes that networks must develop; credentialing of network health care professionals; ensuring the adequacy of provider networks in managed care plans; and outlining policy on the quality assurance and quality improvement programs that networks should implement.
Meanwhile, the Legislature has agreed to study external review of managed care decisions.
In Rhode Island, the House passed a bill that would require health insurers to permit women to make an annual routine visit to a gynecologist without a primary care physician's referral. The Senate also passed the bill, which now goes to the governor.
Earlier this month, Gov. Lincoln Almond signed legislation that mandates a 48-hour minimum hospital stay for a mastectomy and a 24-hour stay for axillary lymph node dissection.
The House and Senate also have passed separate bills broadening coverage for cancer treatments. The two bills would require insurers to cover more experimental cancer treatments. Each bill must be approved by the other chamber before going to the governor.
Gov. Almond in April signed a measure requiring health insurers to pay all medical claims relating to an injury or illness arising out of employment, even if the employer disputes the validity of the claim.
Vermont Gov. Howard Dean signed a measure June 10 requiring health insurers to provide the same level of benefits for mental illnesses as for physical ailments. The measure includes alcohol and drug addictions and bars insurers from setting lower lifetime coverage caps for mental illnesses than for physical conditions.
NORTHEAST Several bills were still in committee last week in Delaware, whose legislative session ended today. Among other things, the bills would require:
Direct access to obstetricians and gynecologists and would let qualified Ob/Gyns apply to be primary care gatekeepers.
Coverage of childhood immunizations for 11 conditions.
Coverage by state-regulated health plans of equipment and supplies for treatment of diabetes.
Coverage of annual mammograms for women 40 and older.
A comprehensive managed care consumer protection bill now in committee calls for, among other things: a state-appointed oversight agency for managed care plans; sufficient primary care providers and specialists and 24-hour telephone access for plan members; a specific waiting time for appointments; and allowing special-needs patients to select a specialist as a primary care provider.
Late last year, the District of Columbia enacted the HMO Act of 1996. The measure forbids HMOs from imposing so-called "gag rules" and requires HMOs to offer a point-of-service option to employers.
Maryland enacted legislation that will require coverage of necessary medical equipment, supplies and outpatient self-management training for people with diabetes. The governor also signed into law measures that will require insurers and HMOs to provide coverage for prostate-specific antigen tests for men aged 40 to 75 and bone mass measurement for diagnosis and treatment of osteoporosis. The laws take effect Oct. 1.
A new law in New Jersey requires insurers to cover hospital stays for 72 hours for a radical mastectomy and 48 hours for a simple mastectomy. Also, legislation approved by the full Senate and the Assembly Health Committee would require HMOs to offer a point-of-service option.
Legislation is pending in the New York Senate that would give managed care organizations the same liability as physicians for medical malpractice suits. An identical bill is pending in the Assembly.
If the bill is not passed by the time the session adjourns in early July, it will remain active in the next session beginning in January.
A new law in West Virginia that goes into effect July 11 bars life and health insurers from denying, canceling or not renewing coverage for victims of abuse. The law also prohibits adding surcharges or rating factors to policies covering victims of abuse.
Pennsylvania did not enact any significant health care legislation.
Alabama enacted several reforms during its legislative session, which ended May 19. Gov. Tony Knolls signed the measures, which:
Repeal the mandates making federal and state funds available for early intervention services for all eligible infants and toddlers with disabilities and their families.
Give the insurance commissioner authority to issue regulations to create a high-risk health insurance pool and to promote the availability of coverage to small employers, regardless of worker health status or claims experience.
Require health plans that offer coverage for mastectomies to cover mammograms at least every two years for women ages 40 to 49 and annually for women age 50 and older.
Subject HMOs to the same premium tax rates as health insurers.
Prohibit genetic testing of enrollees for cancer risks.
A Florida law sweeps aside one of the "gatekeeper" functions of primary care physicians. Under a "direct access bill" that became law without Gov. Lawton Chiles' signature, managed care subscribers may visit a dermatologist up to five times a year without a referral from a primary care physician.
Other Florida reforms:
Prohibit HMOs from including "gag clauses" in provider contracts.
Require HMOs to respond promptly to complaints, advise subscribers of their rights to file a written grievance and establish a procedure for addressing urgent grievances.
Provide that HMOs inform patients of the organization's quality assurance program and procedures for determining provider credentialing and when services are deemed medically necessary.
Require insurers to cover prosthetic devices and reconstructive surgery in some cases after mastectomy. This law, which goes into effect Oct. 1, bars insurers from denying or canceling coverage for policyholders who have had breast cancer. The law also gives physicians authority to determine hospital stays after mastectomies.
Lawmakers also passed legislation that brings Florida into compliance with the federal Health Insurance Portability and Accountability Act of 1996.
The Louisiana Legislature earlier this month narrowly passed the "Rural Hospital Preservation Act," which includes a hotly contested "any willing provider" provision. The bill would require managed care organizations to contract with all hospitals and the providers who work in those hospitals in parishes with 65,000 or fewer residents. The law would cover most of Louisiana's 64 parishes, excluding only New Orleans, Baton Rouge and a handful of other cities, according to the Louisiana Managed Healthcare Assn. The bill was sent to Gov. Mike Foster last week.
Another bill the Legislature approved and that Gov. Foster is expected to sign would let the state Department of Health and Department of Insurance set standards for provider and consumer complaint resolution and utilization review.
Louisiana lawmakers also considered a proposal to require managed care organizations to meet several mandates already imposed on insurers, including requiring payment within 30 days of claims from participants in point-of-service plans. That measure was passed last week and is awaiting the governor's signature.
The North Carolina Senate, which is still in session, approved three managed care bills. The most sweeping would require insurers to provide coverage for mental illness and chemical dependency equal to that for physical ailments. If passed by the House, the measure would take effect with policies issued or renewed beginning Jan. 1, 1998. Another managed care bill would prohibit gag rules and require that health benefit plans provide coverage for emergency room services under specified circumstances. The third bill would require that both patient and physician be consulted before a mastectomy patient is discharged from the hospital. All three measures are before a House committee.
Tennessee Gov. Don Sundquist signed a bill requiring insurers to cover the cost of equipment and supplies such as syringes and blood glucose monitors needed by diabetes patients. The law also requires insurers to cover the cost of training and education to help patients manage the disease.
The Virginia General Assembly approved three managed care bills that were signed into law by Gov. George Allen and take effect July 1.
One will require HMOs to provide 24-hour member access to medical care or 24-hour telephone access to a physician or licensed health care professional. The new law also will require HMOs to reimburse hospital emergency facilities and providers for initial screenings and other specified services when a member was referred to the emergency room by a participating physician.
Another law requires the commissioner of health to examine HMOs' quality of services and will require HMOs to inform members of the grievance system.
The third law will require plans that cover prescriptions to offer coverage for contraceptives.
No significant health care legislation was enacted in Georgia, Mississippi or South Carolina. The Kentucky Legislature was not in session this year.(continued in part 3).