Note: Usually excluded, even from provisions with very broad scope, are workers’ compensation-related plans, long-term care plans, disability income plans, and single-disease and similarly restricted plans.  The key criterion for determining whether an entity will be regulated as an HMO is typically prepayment.  The key criterion for determining whether an entity will be regulated as a managed care organization, where state laws relate to such entities, is adoption of restrictions or incentives affecting choice of provider (although some states, e.g., Montana, exclude PPOs and other networks “operated in a fee-for-service indemnity environment”  from the definition of managed care plan) (Mont. Code Ann. 33-36-103(15)).

Alabama

Link to Alabama Legislature: http://www.legislature.state.al.us/misc/links/links.html

Consumer/Patient Protections

Access
*Ala. Admin. Code r. 420-5-6-.06 (1998) – standing referrals – HMOs must have a system in place to ensure that enrollees receive medically necessary referrals.; in those cases in which a health condition of ongoing or chronic status has been established and the need for specialized care has been determined, the referring physician may authorize in advance a number of visits to a specialty physician so that the enrollee may proceed directly to the specialty physician without first meeting with the referring physician (without incurring increased financial liability).
Ala. Code § 27-94-4 (1997) – OB/GYNs – health benefit plans (inclusive term) must permit OB/GYNs to serve as PCPs and allow patients direct access to OB/GYNs for specified services.

Complaints/UR
Ala. Code § 27-21A-10 – complaints – HMOs are required to establish a complaint system (typical of HMO model act-type provisions that require HMOs to establish a complaint system and get regulatory approval but do not set timeframes, etc.).
Ala. Admin. Code r. 420-5-6-.08(1998) – grievances – HMOs are to have three levels of review, with notice of right to appeal at each stage; HMO is to specify time limits, no more than 45 days, for disposition of grievances at each level of review.*

HMO Protections
Ala. Code § 27-21A-23 – vicarious liability – HMOs authorized by the state are deemed not to be engaged in the practice of medicine and no person participating in the arrangements of an HMO other than the actual provider of services or supplies to enrollees shall be liable for negligence, misfeasance, nonfeasance or malpractice in connection with the furnishing of such services and supplies.

Selected Benefit Mandates (examples; not intended to be exhaustive):
Ala. Code § 27-1-10.1 (1997) – off-label uses of drugs – any insurance policy that provides coverage for drugs is required to provide coverage for off-label use of drugs (not restricted to cancer)

Ala. Admin. Code r. 420-5-6-.04 (1998) – basic services – HMOs are required to provide “basic health services,” which include emergency care (defined term, although no reference to prudent layperson), etc.

+The state health agency is expected to issue regulations that establish tighter timeframes for handling grievances, etc., shortly.

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Alaska

Link to Alaska Legislature: http://www.legis.state.ak.us/folhome.htm

Consumer/Patient Protections

Complaints/UR
1998 Alaska Sess. Laws Ch. 60, Sec. 5 (adding § 21.86.150(i)(3)) – denials of coverage – HMOs may not deny health care coverage unless the enrollee has been examined by at least 2 physicians.
1998 Alaska Sess. Laws Ch. 60, Sec. 5 (adding § 21.86.150(j)) – denials of benefits – HMO UR decisions about medical necessity may only be made by a provider in the relevant specialty or subspecialty after consultation with covered person’s provider.

Disclosure
1998 Alaska Sess. Laws Ch. 60, Sec. 5 (adding § 21.86.150(i)(1)) – gag clauses – HMOs may not “cause, request, or knowingly permit” the imposition of limits on provider communication with patients regarding health care services (includes criticism of the HMO).

Prohibition on Incentives
1998 Alaska Sess. Laws Ch. 60, Sec. 5 (adding § 21.86.150(i)(4)) – incentives – HMOs may not “cause, request, or knowingly permit” financial incentives to be given or offered to a provider for denying or delaying health care services.

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Arizona

Link to Arizona Legislature : http://www.azleg.state.az.us/

Consumer/Patient Protections

Complaints/UR
Ariz. Rev. Stat. Ann. §§ 20-2530 to 20-2539 (West 1997) – independent review – applies to all health care insurers (inclusive definition), with an ERISA preemption caveat for self-funded plans; does not create a private right of action ; requires insurers to have at least 4 levels of review: an expedited medical review, an informal reconsideration, a formal appeal process, and an external independent review; reviewers must have certain qualifications; timeframes are specified for each level of review; IR decisions are subject to judicial review; the insurer pays the IR fees.

 Disclosure
Ariz. Rev. Stat. Ann. § 20-1076(A)(6) (West 1997) – incentive disclosure – health care services organizations must provide a concise description of any incentives or penalties intended to encourage plan providers to withhold services or minimize or avoid referrals to specialists; does not create a private right of action; parallel provisions for small employer plans at § 20-2323(h)(6).
Ariz. Rev. Stat. Ann. § 20-1076(A)(5) (West 1997) – formulary disclosure – other disclosure items include information concerning formularies.
Ariz. Rev. Stat. Ann. § 20-118 (West 1997) – gag clauses – “no person” may restrict or prohibit, by means of policy or contract, good faith communication between provider and patient concerning health care needs, treatment options, health care risks or benefits (same language is repeated in sections governing specific types of insurers, e.g., § 20-1061 (health care services organizations), §§ 20-827, 20-833 (hospital and other service corporations), § 20-934 (benefit insurers).

 Emergency Care
Ariz. Rev. Stat. Ann. § 20-2803 (West 1997) – emergency care – health care services plans (inclusive term) must cover an initial medical screening exam and any immediately necessary stabilizing treatment required under EMTALA without prior authorization; for necessary follow-up care, prior authorization is deemed granted unless a request is denied within a reasonable period of time; certain kinds of follow-up care must be covered unless the plan makes alternative arrangements for the patient’s care.

Nondiscrimination
*Ariz. Rev. Stat. Ann. § 20-1057 (West 1997) – discrimination – health care services organizations must provide specified basic health care services and may not cancel a plan because of a health status-related factor or frequency of utilization of basic health care services of an enrollee or group of enrollees.

Selected Benefit Mandates
Ariz. Rev. Stat. Ann. § 20-826 (West 1997) – home health services - hospital and other service corporations must pay benefits for any home health services prescribed by a physician in lieu of hospital services (also §§ 20-1402, 1404 for group and blanket disability insurance).
Ariz. Rev. Stat. Ann. § 20-826 (West 1997) – post-mastectomy breast reconstruction – applies to hospital and other service corporations that cover mastectomies (also § 20-1057 for health care services organizations, §§ 20-1402, 1404 for group and blanket disability insurance).
Note: § 20-1061 makes health care services organizations subject to the statutory provisions concerning unfair trade practices and frauds.

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Arkansas

Link to Arkansas Legislature: http://www.arkleg.state.ar.us/lpbin/lpext.dll

Consumer/Patient Protections

Access
*Ark. Code Ann. § 23-99-408 (Michie 1997)– continuity of care – applies to insurers restricting providers; new patient who is being treated by nonparticipating provider for a current episode of an acute condition may continue that treatment as an in-network benefit until earlier of end of treatment episode and 90 days; patient whose provider is terminated may continue to receive care as an in-network benefit until earlier of end of treatment for acute condition and 90 days.
Ark. Code Ann. § 23-99-406 (Michie 1997) – OB/GYNs – health insurers must permit direct access.

Complaints/UR
Ark. Code Ann. § 23-99-410 (Michie 1997) – grievances – applies to all managed care plans; no specific timetables or kinds of review, simple “prompt and meaningful review” in cases of denial with “prompt” notice in writing of the outcome with “specific findings” relating to the grievance.

Disclosure
Ark. Code Ann. § 23-99-407 (Michie 1997) – gag clauses – no participating provider may be “prohibited, restricted or penalized in any way” in connection with disclosure of any health care information (extends to UR processes and financial incentives).
Ark. Code Ann. § 23-99-413 (Michie 1997) – formularies –health insurers must provide to prospective policyholders, policyholders and covered persons, upon request, among other things, information concerning the existence of formularies and prior approval requirements for prescription drugs, and criteria by which providers are evaluated for participation (also available to providers upon request).

Emergency Care
Ark. Code Ann. § 20-9-309 (Michie 1997) – emergency care – prudent layperson standard, no preauthorization required.

Formularies
*Ark. Code Ann. § 23-99-409 (Michie 1997) – nonformulary drugs – applies to insurers using formularies; each insurer must have a written procedure whereby covered persons can obtain “without penalty and in a timely fashion,” specific drugs and medications not included in the formulary when the formulary’s equivalent has been ineffective or causes or can be expected to cause an adverse reaction.

Selected Benefit Mandates
Ark. Code Ann. § 23-79-147 (as amended by SB 151, 1999 Ark Legis. Serv.) – off-label uses of drugs – applies to any insurance policy that provides coverage for prescription drugs; limited to use for the treatment of cancer; standard qualifications concerning backing in the medical literature.
Ark. Code Ann. § 23-99-405 (Michie 1997) – post-mastectomy breast reconstruction – applies to health insurers that cover mastectomies.
Ark. Code Ann. §§ 23-79-601 to 607 (Michie 1997) – diabetes – applies to all health insurance policies (inclusive term); requires coverage of self-management training and medically necessary equipment, supplies and services.

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California

Consumer/Patient Protections

Access
Cal. Health & Safety Code § 1367 (West 1998) – continuity of care/referrals – admonition that health care service plans (= entities that cover services in return for a prepaid or periodic charge) furnish “services in a manner providing continuity of care” and ready referral to other providers “as may be appropriate consistent with good professional practice.”
*Cal. Health & Safety Code § 1373.96 (West 1999) – continuity of care – plans must, at enrollee request, cover continuing treatment by a terminated provider for an acute condition, serious chronic condition, or pregnancy (does not apply to voluntary departure or termination for cause, and provider must agree to certain terms); for an acute or serious chronic condition, must cover services for up to 90 days or longer if necessary for a safe transfer as determined by the plan in consultation with the terminated provider, consistent with good professional practice; serious chronic condition defined as “a medical condition due to a disease, illness, or other medical problem or medical disorder that is serious in nature, and either persists without full cure or worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration” (parallel provisions for life and disability insurers are at Cal. Ins. Code § 10133.56).
*Cal. Health & Safety Code § 1374.16(a) (West 1999) – standing referrals/specialists as PCPs – plans must have a procedure that provides for a standing referral to a specialist if the PCP determines in consultation with the specialist, if any, and the plan medical director/designee that an enrollee needs continuing specialist care; may involve treatment plan that limits visits or period of time; plan must have a procedure that provides for referral to a specialist/specialty care center for the purpose of coordinating the enrollee’s health care, where a condition or disease requires specialized medical care over a prolonged period of time and is life-threatening, degenerative, or disabling (determination of medical necessity is made by the PCP in consultation with specialist/center if any and the medical director/designee); may involve treatment plan; after the referral is made, the specialist is authorized to provide services within the area of expertise in the same manner as the PCP, subject to the terms of any treatment plan; determinations must be made within 3 b.d. of receipt of request and all necessary information, and referral must be made within 4 b.d. of submission of treatment plan, if any, to the medical director/designee; obligation to make OON referral only where there is no appropriate IN specialist (as determined by the PCP in consultation with the medical director).
Cal. Health & Safety Code § 1367.69 (West 1998) – OB/GYNs – plans must permit OB/GYNs to serve as PCPs (direct access is mandated under 1998 Cal. Legis. Serv. § 1367.95 (West)).

Complaints/UR
Cal. Health & Safety Code § 1367 (West 1998) – noninterference – the section on administrative capacity contains a requirement that a plan “be able to demonstrate to the department that medical decisions are rendered by qualified medical providers, unhindered by fiscal and administrative management.”
Cal. Health & Safety Code §§ 1368, 1368.01 (West 1998) – grievances – plans must establish system; some timeframes specified, and recourse to department permitted after 60 days in the process; a status report if not a resolution required within 30 days.
Cal. Health & Safety Code § 1368.02 (West 1998) – ombudsman – the commissioner is to establish a toll-free number and designate an ombudsperson.
Cal. Health & Safety Code § 1368.1 (West 1998) – expedited review – a plan that denies coverage to an enrollee with a terminal illness must provide certain information within 5 business days and provide the enrollee with the opportunity to attend a conference within 30 calendar days.
Cal. Health & Safety Code § 1370.2 (West 1998) – reviewer qualifications – plans must insure that reviewers of contested claims have appropriate qualifications.
Cal. Health & Safety Code § 1370.4 (West 1998) – independent review – plans must provide IR for enrollees with terminal conditions seeking non-standard therapies that would be covered but for plan determinations that they are experimental; does not apply to Medi-Cal beneficiaries; costs are borne by the plan; timeframe is 30 days or 7 days for expedited review; a majority decision is binding on the plan and an even split is deemed a decision in favor of coverage (parallel provisions for life and disability insurers are at Cal. Ins. Code § 10145.3).

Disclosure
Cal. Bus. & Prof. Code §§ 2056, 2056.1 (West 1998) – gag clauses/nonretaliation – no person may penalize a physician or surgeon for principally for advocating for medically appropriate health care or prohibit or discourage a physician or surgeon from communicating to a patient information in furtherance of medically appropriate health care; medically appropriate health care in a hospital is defined by the medical staff, consistent with the applicable legal standard of care; plans and their contracting entities may not include provisions in their contracts that interfere with the ability of a licensed health care provider to communicate with a patient regarding his or her health care, including communications regarding treatment options, alternative plans, or other coverage arrangements (but may prohibit solicitation for alternative coverage for the primary purpose of securing financial gain).
Cal. Health & Safety Code § 1367.10 (West 1998) – incentive disclosure – plans that affect choice of provider must disclose the basic method of reimbursement and whether financial bonuses or incentives are used.
1998 Cal. Legis. Serv. § 1367.22 (West) – formulary disclosure – plans must disclose current list of formulary drugs to members of the public upon request.
Cal. Health & Safety Code § 1373.96 (West 1999) – continuity of care – a description of how to request continuity of care must be included in the evidence of coverage and disclosure form after 7/1/99.
Cal. Health & Safety Code § 1363 (West 1999) – matrix – beginning 7/1/99, plans in individual or small group markets must display information in uniform benefits and coverage matrix that includes category descriptions with corresponding copayments and limitations (includes prescription drug coverage, DME, mental health, chemical dependency, home health).

Emergency Care
Cal. Health & Safety Code § 1371.4 (West 1998) – emergency care – plans, with some exceptions, cannot require preauthorization for emergency care so long as emergency services are legally mandated without regard to ability to pay, unless the enrollee did not require emergency care and reasonably should have known that (no preauthorization for ambulance services per 1998 Cal. Legis. Serv. § 1371.5 (West), also linked to enrollee’s reasonable belief).

Formularies
*1998 Cal. Legis. Serv. § 1367.24 (West) – nonformulary drugs – plans that cover prescription drugs must establish an “expeditious” process by which providers may obtain authorization for medically necessary nonformulary drugs.
*1998 Cal. Legis. Serv. § 1367.22 (West) – maintenance drugs – plans that cover prescription drugs may not exclude a drug previously approved for coverage for the enrollee’s medical condition if the provider continues to prescribe it (eff. 7/1/99).

Prohibition on Incentives
Cal. Bus. & Prof. Code § 511, Cal. Health & Safety Code § 1348.6 (West) – no contract between a plan and a licensed health care practitioner, or subcontract between a practitioner/group that contracts with a plan or insurer and another practitioner/group, shall contain an incentive plan that includes a specific payment made to a licensed health care practitioner as an inducement to deny, limit or delay specific, medically necessary, and appropriate services covered under the contract and provided with respect to a specific enrollee or group of enrollees with similar medical conditions (does not prohibit incentive plans that involve general payments or shared-risk arrangements that are not tied to specific medical decisions involving specific enrollees/groups with similar medical conditions, and payments are deemed confidential information) (parallel provisions for life and disability insurers are at Cal. Ins. Code § 10175.5).

Consumer Participation
Cal. Health & Safety Code § 1369 – policy – plans must establish procedures to permit members to participate in establishing the public policy of the plan.

Provider Protections
Cal. Bus. & Prof. Code § 510 (West 1998) – nonretaliation – any retaliation against a health care practitioner principally for advocating for appropriate health care is declared against public policy (see also § 2056).

Selected Benefit Mandates
Cal. Health & Safety Code § 1367.21 (West 1998) – off-label uses of drugs – plans that provide coverage for prescription drugs cannot exclude off-label use of drugs; limited to life-threatening conditions; Medi-Cal plans are exempt.
Cal. Health & Safety Code § 1367.18 (West 1998) – orthotic/prosthetic devices – most plans must cover.
Cal. Health & Safety Code § 1367.19 (West 1998) – special footware – most plans must cover.
1998 Cal. Legis. Serv. AB 2003/Ch. 790 – dental – plans required to cover general anesthesia and associated charges for dental treatment of certain groups, including those with developmental disabilities, when treatment must be rendered in a hospital or surgery center due to the physical or mental condition of the patient.
Cal. Code Regs. tit. 10, § 1300.67 – basic services – health care services plans must provide basic health care services, including medically appropriate home health services.  (See also AB 1899, 1999 Legis. Serv. ch. 1026).

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Colorado

Consumer/Patient Protections

Access
*Colo. Rev. Stat. Ann. § 10-16-704(2) – OON referrals – where no participating provider is available to provide a covered benefit, the carrier must arrange for a referral to a provider with the necessary expertise and ensure that the cost to the covered person is equivalent to that for an in-network referral.
*Colo. Rev. Stat. Ann. § 10-16-705(4) – continuity of care – if a managed care plan terminates a provider without proper notice, the plan must permit covered persons to continue receiving care for 60 days from the termination date.
*Colo. Rev. Stat. Ann. § 10-16-704(9) – access plan – for each managed care network the carrier must develop an access plan that, among other things, describes the carrier’s efforts to address the needs of covered persons with physical and mental disabilities (among other groups).
Colo. Rev. Stat. Ann. § 10-16-107 – OB/GYN – managed care plans must either allow women direct access to a participating OB/GYN or CNM or not unreasonably withhold a referral when requested.

Complaints/UR
Colo. Rev. Stat. Ann. § 10-16-705(14) – preauthorization – provider contracts must state that the sole responsibility for obtaining preauthorizations rests with the participating provider who recommends or orders a service.
Colo. Code of Reg. § 4-2-17 – UR/review decisions – applies to all health plans that base decisions concerning claims on UR; for prospective review, determination within 2 b.d. of obtaining all necessary information, with notice of an adverse determination within 1 b..d of decision; for concurrent review, determination within 1 b.d., with notice of an AD within 1 b.d. (service continued without liability to covered person until notice given); content of notice specified, including instructions for initiating appeal and requesting statement of clinical rationale; may request reconsideration; covered person may designate representative to exercise rights.
Colo. Code of Reg. § 4-2-17 – UR/appeals – first level appeals must be evaluated by a physician in consultation with appropriate clinical peer(s), in each case with no involvement in initial AD, and decision must be rendered and notice given within 20 b.d. of request; notice must include credentials of reviewers, medical rationale and reference to evidence used as basis for decision, and description of process for requesting second level appeal; second level appeal must involve a panel with at least 3 people, the majority of whom were not previously involved and are health care professionals with appropriate expertise (also no direct financial interest in outcome and not plan employees), with meeting within 45 days of receipt of request, and 15 b.d. advance notice with opportunity for covered person to appear, or if not practical for geographic reasons, opportunity to communicate via appropriate technology at carrier expense, plus provision of all relevant information not confidential or privileged upon request; covered person has right to attend, present, submit supporting material, ask questions, and be assisted or represented by another (notice must advise of these rights); written decision within 5 b.d. of meeting, with notice that includes right to contact insurance commissioner’s office and telephone number and address.
Colo. Code of Reg. § 4-2-17 – UR/expedited appeals – where standard review procedures would seriously jeopardize the life or health of the covered person or jeopardize his/her ability to regain maximum function, decision must be made as expeditiously as the medical condition requires, but in no event more than 72 hours after review is commenced (must be provided for all requests concerning follow-up to emergency care).

Emergency Care
Colo. Rev. Stat. Ann. § 10-16-704(5) – emergency care – managed care plans cannot deny benefits for emergency services based upon failure to comply with notification provisions where the medical condition prevented timely notification.
Colo.  Code of Reg. § 4-2-17(VI)(G) – UR/ER – adopts prudent layperson standard for establishing necessity of emergency services, situations in which prior authorization cannot be required, necessity of obtaining care from OON provider (if prudent layperson would have reasonably believed that use of contracting provider would result in delay that would worsen emergency).

Provider Protections
Colo. Rev. Stat. Ann. §§ 10-16-121, 10-16-705(11) – nonretaliation – carriers’ contracts must contain a provision stating that neither the provider nor the carrier shall be prohibited from protesting or expressing disagreement with a medical decision, policy or practice, and that the carrier shall not terminate the contract because the provider expresses disagreement with a decision to deny or limit benefits or assists a patient in seeking reconsideration or discusses with any patient any aspect of the patient’s medical condition or treatment options or plan policy provisions or recommends a health plan based on personal knowledge of the patient’s health needs (but can prohibit maliciously critical comments and terminate for material misrepresentation); carriers are prohibited from penalizing providers for good faith reports to regulators or discussions of financial arrangements with patients.

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Connecticut

Link to Connecticut Legislature: http://prdbasis.cga.state.ct.us/BASIS/TSPBKCP/LIN1/PUB/MSF

Consumer/Patient Protections

Access
Conn. Gen. Stat. Ann. § 38a-530b – OB/GYNs – group health carriers must permit direct access to OB/GYNs and may permit OB/GYNs to serve as PCPs.

Complaints/UR
1997 Conn. Legis. Serv. P.A. No. 97-99 § 14 – grievances – general requirement that MCO have one and inform enrollees about it.
1997 Conn. Legis. Serv. P.A. No. 97-99 § 20 – independent review – any enrollee or provider with enrollee consent may appeal a denial to the commissioner, but only after exhausting internal MCO or URO mechanisms; the filing fee is $25 (waivable); the decision is binding.
Conn. Gen. Stat. Ann. §§ 38a-226-38a-226d – UR standards – sets timeframes for UR, specifies content for notices, qualifications for reviewers, and types of appeals that must be provided, including expedited review for emergency or life-threatening situations; prohibits financial incentives based on number of denials.

Disclosure
1997 Conn. Legis. Serv. P.A. No. 97-99 § 12 – gag clauses – MCO contracts with providers may not prohibit discussion of any treatment options with patients, or disclosure of compensation methods to an enrollee who inquires.
1997 Conn. Legis. Serv. P.A. No. 97-99 § 8 – UR disclosure – MCOs must provide enrollees and potential enrollees with a plan description including the number of UR denials and the number upheld and reversed on appeal (must also include enrollee satisfaction information).  (Procedures for maintaining confidentiality must also be described.)
1998 Conn. Legis. Serv. amendment to P.A. No. 97-99 § 8 – formulary disclosure – plan descriptions must also describe the use of drug formularies or any limits on the availability of prescription drugs and the procedure for obtaining information on the availability of specific drugs covered.
1997 Conn. Legis. Serv. P.A. No. 97-99 § 13 – report cards – consumer report cards are to be distributed by the commissioner of insurance beginning 3/15/99.

Emergency Care
1997 Conn. Legis. Serv. P.A. No. 97-99 § 26 – emergency care – adopts prudent layperson standard.
Conn. Gen. Stat. Ann. § 38a-525a – emergency care – group health policies may not direct an enrollee to obtain approval before calling 9-1-1 in a life or limb threatening emergency (enrollee belief).

Provider Protections
*1997 Conn. Legis. Serv. P.A. No. 97-99 § 7 – provider profiling – MCOs that measure provider performance must make allowances for the severity of illness or condition of the patient mix and for patients with multiple illnesses or conditions, must share the documentation with regulators, and must inform enrollees and providers of their methodology upon request.
1997 Conn. Legis. Serv. P.A. No. 97-99 § 9 – nonretaliation – MCOs are prohibited from retaliating against providers for assisting enrollees with appeals.

Selected Benefit Mandates
Con. Gen. Stat. Ann. § 38a-518b – off-label uses of drugs – applies to group health policies, limited to cancer.
Con. Gen. Stat. Ann. § 38a-520 –home health services – applies to group health policies, includes medical social services.

Miscellaneous
1997 Conn. Legis. Serv. P.A. No. 97-99 § 21 – compliance with laws – MCOs must conform to all applicable state and federal antidiscrimination and confidentiality statutes and have written confidentiality policies and procedures.
1997 Conn. Legis. Serv. P.A. No. 97-99 § 11 – coinsurance payments – coinsurance payments must be calculated based on the lesser of provider/vendor charges and or the amount payable by the MCO.
1997 Conn. Legis. Serv. P.A. No. 97-99 § 10 – no limitation of action – MCOs may not limit causes of action or contract rights otherwise possessed by enrollees by contract.
1997 Conn. Legis. Serv. P.A. No. 97-99 § 27 – mental health parity – group health insurance policies must provide coverage for biologically-based mental or nervous conditions at least equal to coverage for medical or surgical conditions. (dealt with in separate legislation in most other states)

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Delaware

Consumer/Patient Protections

 Access
*Del. Reg. § 69.305 – continuity of care – except in cases where termination was due to unsafe practices, MCOs must assure continued coverage of services at the contract price for up to 120 days [from notice? termination?] in cases where it is medically necessary for the enrollee to continue treatment with the terminated provider.
Del. Code Ann. tit. 18, §§ 3342, 3556 – OB/GYNs – insurers must permit OB/GYNs to serve as PCPs if certain  conditions are met and must allow direct access to OB/GYNs.
Del. Reg. § 69.402 – access plan – MCOs must annually submit to the insurance department policies and procedures for measuring and assessing the adequacy of the network.
Del. Reg. § 69.402(B) – OON providers – MCOs shall make acceptable service arrangements with the provider and enrollee if the appropriate level of service is not available at no extra cost to the enrollee.

Complaints/UR
Del. Reg. § 69.403 – UR/general standards – protocols must be periodically reviewed and updated, and with the exception of internal or proprietary quantitative thresholds, be readily available, upon request, to affected providers and enrollees; compensation to persons providing UR services shall not contain direct or indirect incentives to make inappropriate decisions, e.g., compensation may not based on the quantity or type of adverse determinations rendered; all determinations must be made by appropriately qualified staff, and all determinations to deny or limit an admission, service, procedure or extension of stay must be rendered by a physician and must made in accordance with clinical and medical criteria and standards and take into account the individualized needs of the enrollee.
Del. Reg. § 69.404 – UR/appeals – three stages (informal internal, formal internal, and formal external); correspond to Colorado in terms of general parameters, except for stage 3, external review; stage 1 timeframes are 72 hr. maximum for expedited appeals (imminent, emergent or serious threat to health), 5 b.d. for others; in stage 2, enrollee has right to attend, present, submit supporting material, etc., and timeframe is 72 hr. maximum for expedited review, 30 days from receipt of request for others (with extension for reasonable cause).
Del. Reg. § 69.404 – UR/independent review – MCO charged with maintaining formal external review process, with review meeting within 45 days of request; includes provision for enrollee to attend/communicate via appropriate technology at MCO request, and rights similar to stage 2, with written decision within 5 b.d. of meeting.
Del. Reg. § 69.404(A)(3) – UR/MCO-appointed representative – at any stage of the appeal process, upon enrollee request, the MCO must appoint a member of its staff with no direct involvement in the case to represent/assist the enrollee, and the appealing enrollee must be notified of this right.

Disclosure
Del. Code Ann. tit. 18, §§ 3303, 6407 – gag clauses – health insurance policies/HMO contracts may not contain any provision prohibiting health care providers from giving patients information regarding diagnoses, prognoses, and treatment options.

Emergency Care
Del. Reg. §§ 69.1, 69.402(C) – emergency care – adopts prudent layperson standard in definition of emergency medical condition; MCOs may not require prior authorization for treatment of such a condition (= screen and stabilize); emergency and urgent care services must include 24x7 medical and psychiatric care and out of area care for urgent or emergency conditions where the enrollee cannot reasonably access IN services.

Nondiscrimination
*Del. Reg. § 69.307 – nondiscrimination – no MCO may cancel or refuse to renew an enrollee solely on the basis of his/her health; pre-existing condition clauses may not extend longer than 12 months from enrollment.

Prohibition on Incentives
Del. Reg. § 69.307 – incentives – incentives to a provider to provide less than medically necessary services are prohibited.

Provider Protections
Del. Code Ann. tit. 18, §§ 3339, 6408 – nonretaliation – insurers/HMOs may not refuse to contract with or compensate providers solely based on their good faith communication with patients concerning the insurer’s products or services.
Del. Reg. § 69.307 – nonretaliation – MCOs may not penalize providers for good faith reports to state authorities re threats to patient health or welfare.
*Del. Reg. § 69.401(C) – nondiscrimination/selection criteria – professional selection criteria shall not be established in a manner that would allow an MCO to avoid high-risk populations by excluding providers because they are located in geographic areas that contain populations or providers presenting a risk of higher than average claims, losses or health services utilization, or that would exclude providers because they treat or specialize in treating populations presenting a risk of higher than average claims, losses or health services utilization.

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District of Columbia

Consumer/Patient Protections

Disclosure
D.C. Code Ann. § 35-4506(h) – gag clauses – HMO contracts with providers may not interfere in discussions between patient and provider concerning treatment options; carrier contracts with providers must require providers to discuss treatment options with patients; HMOs may not retaliate against providers solely based on discussion of treatment options with patients.

Provider Protections
D.C. Code Ann. § 35-4506(h) – nonretaliation – HMOs may not retaliate against providers solely based on discussion of treatment options with patients.

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Florida

Consumer/Patient Protections

Access
*Fla. Stat. Ann. § 641.51(5) – OON referrals – HMOs and prepaid plans must have a policy to determine when referrals to out-of-network “specially qualified providers” should be provided to address “unique medical needs.”
*Fla. Stat. Ann. § 641.51(6) – standing referrals – HMOs and prepaid plans must have policies and procedures for the provision of standing referrals to subscribers with chronic and disabling conditions which require ongoing specialty care.
*Fla. Stat. Ann. § 641.51(7) – continuity of care – HMOs and prepaid plans must allow subscribers with life-threatening or disabling and degenerative conditions (plus pregnancy) to continue care for 60 days with a terminated provider.
Fla. Stat. Ann. § 641.19 - OB/GYNs – HMOs must permit participating OB/GYNs to serve as PCPs.
Fla. Stat. Ann. § 641.31(33) – dermatologists – HMOs that offer dermatological services must provide direct access to participating dermatologists for office visits and minor procedures and testing, within certain limits.

Complaints/UR
Fla. Stat. Ann. § 641.511 – grievances – one year window for submission of grievances to HMOs/prepaid plans; 30-day window for internal appeal of adverse determinations; minimum requirements for grievance procedures include provision of a toll-free number, expedited review for grievances classified as urgent, and development of a procedure for assisting individuals who are unable to submit a written grievance; 60-90 day timeframe for action on standard reviews, shortened to 72 hours for expedited review; service continued without liability to subscriber until notice in the case of concurrent review; subject to administrative sanctions for noncompliance; no independent review until internal review is completed, but subscriber may submit a copy of grievance to agency at any time.
Fla. Stat. Ann. § 408.7056 – independent review – state regulatory agency is to implement a consumer assistance program that includes a review panel that meets periodically to consider cases not resolved through plans (HMOs, PPOs) internal grievance procedures; the panel consists of agency and insurance department staff, which may contract for medical expertise; focused on instances of violation of law; parties have opportunity to appear before panel and panel must notify them that it has transmitted its recommendations to the agency within 30 days after the meeting; the agency sends a response to the parties within 30 days of its receipt of a recommendation.
Fla. Stat. Ann. § 641.60 – consumer assistance – establishes statewide managed care ombudsman committee.

Disclosure
Fla. Stat. Ann. § 641.54 – disclosure – HMOs and prepaid plans must provide information concerning the following upon request: the authorization and referral process, determinations of medical necessity, prescription drug benefits, policies and procedures respecting confidentiality, the decision making process regarding experimental treatments, and policies and procedures for addressing the needs of NESPs, etc.
Fla. Stat. Ann. § 641.315(8) – gag clauses – HMOs contracts with providers may not contain any provision restricting communication with patients regarding medical care or treatment options.
Fla. Stat. Ann. § 641.3903(13) – misrepresentation – HMOs may not knowingly mislead potential enrollees as to the availability of providers.

Emergency Care
Fla. Stat. Ann. §§ 641. 19, 641.31(12), 641.513 – emergency care – HMOs may not require prior authorization for emergency care or deny payment based on failure to give notice prior to or within a certain time period; HMOs must use the state definitions for emergency condition (which includes concept of reasonable expectation), etc. (§ 627.6472 covers insurance policies with exclusive provider provisions).

Nondiscrimination
*Fla. Stat. Ann. § 641.3903(12) – discrimination – HMOs may not engage or attempt to engage in discriminatory practices that discourage participation on the basis of actual or perceived health status of Medicaid recipients.

Selected Benefit Mandates
Fla. Stat. Ann. § 641.31(26)(a) – diabetes – HMOs and prepaid health plans must cover “all medically appropriate and necessary” equipment, supplies, and services used to treat diabetes.
Fla. Stat. Ann. § 641.31(27) – osteoporosis – HMOs must cover “medically necessary” diagnosis and treatment of osteoporosis for high-risk individuals.
Fla. Stat. Ann. § 641.31(32) – post-mastectomy breast reconstruction – applies to HMOs that cover mastectomies.
Fla. Stat. Ann. § 641.31094 – bones and joints in the facial region – applies to all HMOs that cover surgical procedures involving bones and joints.
Fla. Stat. Ann. § 627.4236 (West 1998) – bone marrow transplants – insurers and HMOs that cover cancer treatment may not exclude coverage for BMTs recommended by the referring and treating physicians as experimental if the particular use is accepted within the appropriate oncological specialty and according to rules developed by the state administrative agency.
Fla. Stat. Ann. § 627.4239 – off-label uses of drugs – applies to all insurers; limited to treatment of cancer.

Miscellaneous
Fla. Stat. Ann. § 641.28 – remedies – in any civil action brought to enforce an HMO contract, the prevailing party is entitled to recover attorney’s fees and court costs.

Insurance Protections (examples below; these provisions do not address problems with managed care per se; many states have similar provisions)
*Fla. Stat. Ann. § 641.31073 – discrimination – HMOs that offer group coverage may not establish rules for eligibility based on health status, medical condition, claims experience, receipt of health care, or disability (but may limit the amount, level or nature of benefits for similarly situated individuals); premium variations are permitted, so long as they apply to all similarly situated individuals. (relation to HIPAA?)
Fla. Stat. Ann. § 641.31 – dependent children - general insurance protections include provisions that require HMOs to (a) cover newborn children, to include necessary care for congenital defects, etc. and (b) provide continuing coverage (beyond age limits) for children who are incapable of self-sustaining employment by reason of mental or physical handicap and dependent.

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Georgia

Consumer/Patient Protections

Access
*Ga. Code Ann. § 33-20A-9(2) – nonformulary drugs – MCOs that use formularies must have a written procedure that allows patients to obtain nonformulary drugs “without penalty and in a timely fashion” where the formulary’s equivalent (a) has been ineffective in treating the patient or (b) causes or is reasonably expected to cause an adverse reaction.
Ga. Code Ann. § 33-24-59 – OB/GYNs – direct access provision applicable to insurers, HMOs, etc.

Complaints/UR
Ga. Code Ann. § 33-20A-5(3) – grievances – MCOs must provide a “prompt and meaningful” hearing for denials, with non-medical director physician representation on the hearing panel; if the outcome is adverse notice must include specific findings.
Ga. Code Ann. § 33-20A-31 – independent review – threshold determination whether treatment sought reasonably appears to be covered; enrollee must have received notice of an adverse decision or a determination that the proposed treatment is excluded as experimental; in the case of an experimental exclusion, the enrollee must have a terminal condition or the enrollee’s ability to regain or maintain maximum function must be impaired by withholding the treatment (in the judgment of the treating physician) and the treating physician (who is board certified or eligible and qualified to treat the condition) certifies that there is no standard treatment available more beneficial than the proposed treatment and that scientifically valid studies using accepted protocols published in peer reviewed literature demonstrate that the proposed treatment is likely to be more beneficial for the enrollee than available standard treatment and the treatment would be covered but for the determination that it is experimental; at least $500 must be at stake; the MCO is required to pay for the independent review; eligible enrollees must be given instructions on how to request review; the IRO decision is final and binding on the MCO; 72 hour expedited review available, otherwise 15 b.d.+; conflict of interest rules apply.
Ga. Code Ann. § 33-20A-31 – IR/medical necessity – for purposes of IR, defined as care based upon generally accepted medical practices in light of conditions at the time of treatment which is (A) appropriate and consistent with the diagnosis and the omission of which could adversely affect or fail to improve the eligible enrollee’s condition; (B) compatible with the standards of acceptable medical practice in the U.S.; (C) provided in a safe and appropriate setting given the nature of the diagnosis and the severity of the symptoms; (D) not provided solely for the convenience of the eligible enrollee or the convenience of the provider; and (E) not primarily custodial care, unless that is a covered benefit.
Ga. Code Ann. § 33-20A-31 – IR/experimental – in making a determination as to whether a treatment is experimental, the expert reviewer must determine whether the treatment has been approved by the FDA or whether medical and scientific evidence (defined term) demonstrates that the expected benefits of the proposed treatment would be greater than the benefits of any available standard treatment and that the adverse risks of the proposed treatment will not be substantially increased over those of standard treatments; for either determination, the reviewer must apply prudent professional practices and assure that at least two documents support the decision.

Disclosure
Ga. Code Ann. § 33-20A-5(1) – incentive disclosure – MCOs must disclose limited utilization incentive plans to enrollees and prospective enrollees upon request (parallel provision covering HMOs only at § 33-21-13(c); parallel provision covering insurers, HMOs, and private health benefit plans at § 31-11-82).

Emergency Care
Ga. Code Ann. §§ 33-20A-3, 33-20A-5, 33-20A-9(1) – emergency care – applies to all managed care plans; prudent layperson standard; if judged necessary by the provider, services may be initiated without prior authorization and MCOs and private health plans must pay (parallel provision relating to HMOs only at § 33-21-18.1).

Prohibition on Incentives
Ga. Code Ann. § 33-20A-6 – incentives – MCOs may not use financial incentive programs that directly compensate providers for providing less than medically necessary and appropriate care, but capitated payment arrangements consistent with the intent of this section are not prohibited.

MCO Liability
Ga. Code Ann. § 51-1-48 (West 1999) (HB 732) – negligence – any person or entity that administers benefits or reviews claims under a managed care plan must exercise ordinary diligence to do so in a timely and appropriate manner in accordance with the practices and standards of the profession of the health care provider generally; any injury or death to an enrollee resulting from a want of such ordinary diligence is a tort from which recovery may be had against the MCO offering the plan (but no punitive damages).

Provider Protections
Ga. Code Ann. § 33-20A-7 – nonretaliation – no health care provider may be penalized for discussing medically necessary or appropriate care with or on behalf of his or her patient.

Selected Benefit Mandates
*Ga. Code Ann. § 33-24-59.1 – clinical trials – any plan that provides major medical coverage for dependent children must cover the routine patient care costs incurred in connection with a dependent child’s participation in an approved clinical trial for the treatment of children’s cancer.
Ga. Code Ann. § 33-24-59.2 – diabetes – managed care plans and other major medical policies or plans must offer coverage.
Miscellaneous
*Ga. Code Ann. § 33-20A-5(3) – QA – MCOs must have a QA program that includes mechanisms to detect both underutilization and overutilization of services. (General mandates to have some kind of QA program are common, undoubtedly part of model HMO act.)

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Hawaii

Consumer/Patient Protections

Complaints/UR
1998 Hawaii Sess. Laws Act 178 § 6 – independent review – after exhausting all internal review and appeal procedures, an enrollee may appeal an adverse decision to a 3-member review panel appointed by the commissioner (an MCO representative and a provider, both uninvolved, and the commissioner or his/her designee).

Disclosure
*1998 Hawaii Sess. Laws Act 178 § 4(b) – disclosure of treatment options – providers in managed care plans must discuss all treatment options with an enrollee and ensure that persons with disabilities have an effective means of communication with the provider and other members of the managed care plan.
1998 Hawaii Sess. Laws Act 178 § 4(d) – gag clauses – managed care plans may not impose any prohibition or negative treatment upon a provider for disclosing any information regarding treatment options or care.

Emergency Care
1998 Hawaii Sess. Laws Act 246, §§ 431.10A-, 432.1-, 432D-  – emergency care – prudent layperson standard; health plans must cover emergency services without prior authorization (out of network, if a prudent layperson would have believed that the time required to reach a participating provider placed him/her in danger, etc.).

Miscellaneous
1998 Hawaii Sess. Laws Act 178 § 10(b)(5) – confidentiality – a managed care plan shall ensure confidentiality of records and shall not disclose individually identifiable data or information pertaining to the diagnosis, treatment, or health of any enrollee, except as provided under law.
1998 Hawaii Sess. Laws Act 178 § 8 – remedies – exclusive enforcement by the commissioner.

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Idaho

Consumer/Patient Protections

Access
Idaho Code § 41-3915(2) – OB/GYNs – MCOs must allow members direct access to OB/GYNs and permit OB/GYNs to serve as PCPs.

Complaints/UR
Idaho Code § 41-3918 – grievances – MCOs must provide “reasonable” procedures to assure “prompt” review.
Idaho Code § 41-3930 – UR standards – MCOs must adopt criteria that are “based on sound patient care and scientific principles” and “sufficiently flexible to allow deviations” when justified, and procedures for timely review by clinical peers; MCOs must respond to requests for prior authorization for non-emergency services within 2 business days.

Disclosure
Idaho Code § 41-3914(1) – formularies – MCOs must provide to enrollees and make available for inspection by public on annual basis, among other things, a statement as to whether the MCO includes a limited formulary and a statement that the formulary will be made available to any prospective member upon request.

Emergency Care
Idaho Code §§ 41-3903(7), 41-3930(2) – emergency care – MCOs may not require prior authorization for emergency services (definition incorporates prudent layperson standard).

Nondiscrimination
*Idaho Code § 41-3915(3) – discrimination – MCOs may not cancel the enrollment of a member or refuse to transfer a member from group to individual basis for reasons relating to health status. (check for this kind of HIPAA-related provision in other states)

Prohibition on Incentives
Idaho Code § 41-3928 – incentive prohibition – MCOs may not employ incentive plans that includes specific payments to providers as an inducement to deny, limit, or delay specific, medically necessary, and appropriate covered services provided with respect to a specific member or group of members with similar medical conditions; incentive plans that involve general payments and shared risk agreements not tied to specific medical decisions involving specific members or groups of members with similar medical conditions are not prohibited.

Consumer Participation
Idaho Code § 41-3916 – policy and operation – MCOs must establish a mechanism to provide members an opportunity to participate in matters of policy and operation.

Provider Protections
Idaho Code § 41-3927(4) – contract terms – MCOs may not require that a provider deny a member access to services not covered by the plan, etc.
Idaho Code § 41-3927(5) – nonretaliation – MCOs may not refuse to contract with or compensate providers solely because they have communicated in good faith with patients regarding the MCO’s products as they relate to the needs of the patients; MCOs may not penalize providers practicing in conformity with community standards solely for advocating on behalf of patients.

Illinois

Consumer/Patient Protections

Access
215 Ill. Comp. Stat. Ann. 125/5-3.1, 5/356r – OB/GYNs – HMOs and other insurers that use PCPs must allow a woman to designate an OB/GYN to whom the woman has direct access.

Complaints/UR
215 Ill. Comp. Stat. Ann. 125/4-6 – complaints – HMOs must have “reasonable procedures” for complaint handling; when a complaint is received by the dept. of insurance, notice is sent to the HMO, which has 21 days to respond.
215 Ill. Comp. Stat. Ann. 125/4-10 – independent second opinions – HMOs must offer review by an unaffiliated physician with the same class of license as the PCP in the event of a dispute between the PCP and HMO regarding the medical necessity of a covered service (with a nonretaliation provision attached).

Selected Benefit Mandates
*215 Ill. Comp. Stat. Ann. 125/4-5 – organ transplants – HMOs may not deny reimbursement for an otherwise covered expense incurred in an organ transplant procedure solely on the basis that the procedure is experimental [i.e., experimental or investigational] unless the Office of Health Care Technology Assessment has determined that the procedure is experimental or there is insufficient data to determine whether it is clinically acceptable.
215 Ill. Comp. Stat. Ann. 125/4-6.3, 5/370r – off-label uses of drugs – applies to HMOs and all group policies that cover prescribed drugs, limited to cancer treatment.

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Indiana

Consumer/Patient Protections

Access
*Ind. Code Ann. § 27-13-36-5 (West 1998) – OON referrals – when a PCP determines that a service is needed and the HMO determines that the type of service is covered and is not available in-network, the PCP and HMO must refer the enrollee to an appropriate out-of-network provider “within a reasonable amount of time and within a reasonable proximity”; payment to the provider is the lesser of the UCR charge for the area or an agreed amount, with the enrollee responsible only for the deductible or copay applicable to in-network care; contract terms penalizing PCPs making this kind of determination are prohibited.
*Ind. Code Ann. §§ 27-13-37-2, 27-13-37-3 (West 1998) – standing referrals/specialists as PCPs – HMOs must develop a system to allow enrollees to use appropriate participating providers to manage their condition when their PCPs determine that this is warranted by the condition, for as along as warranted; contract terms penalizing PCPs making this kind of referral are prohibited; eff. 7/1/99 enrollees must be given a choice of appropriate participating providers when a referral is made.
*Ind. Code Ann. §§ 27-13-36-6, 27-13-36-11 (West 1998) – continuity of care – HMO contracts with providers must require the provider to continue to treat an enrollee for up to 60 days after termination at the enrollee’s election; HMOs must develop standards for continuity of care following enrollment.
Ind. Code Ann. § 27-8-24.7-5 (West 1998) – OB/GYNs – insurers including HMOs must permit OB/GYNs to serve as PCPs.
*Ind. Code Ann. § 27-13-36-10 (West 1998) – access plan – HMOs must demonstrate to the commissioner that they have an access plan to meet the needs of enrollees, including the vulnerable and underserved and NESPs.
*Ind. Code Ann. § 27-13-36-3 (West 1998) – proximity – HMOs that cover specialty medical services and mental and behavioral health services must demonstrate to the department that offered services are located within reasonable proximity to subscribers (eff. 7/1/99).

Complaints/UR
Ind. Code Ann. § 27-13-37-5 (West 1998) – second opinions – HMOs must allow an enrollee to obtain a second opinion from an appropriate participating provider upon request.
Ind. Code Ann. §§ 27-13-10-5 to 27-13-10-13 (West 1998) – grievances – HMOs must accept grievances orally or in writing, offer a toll-free number (capable of handling the languages of the major population groups served), and offer assistance with filing; procedures must include standards for timeliness, under normal circumstances not to exceed 20 business days from the filing date; members of panels that review appeals must be qualified and free of direct conflicts, appeals must be resolved not later than 45 days after the filing date, and grievance resolution notices must contain specified information.
*Ind. Code Ann. §§ 27-13-39-2, 27-13-39-3 (West 1998) – experimental treatments – HMOs must disclose limits on coverage for experimental procedures, drugs, etc., including processes for making determinations and criteria; HMOs must provide enrollees denied services notice of the basis of denial and the right to appeal; in an emergency or where the enrollee’s condition is life-threatening the HMO has 72 hours to complete a review.
Ind. Code Ann. § 27-13-39-1 (West 1998) – technology assessment – HMOs must have procedures to evaluate technologies and their applications for coverage that include review of information from regulatory bodies and published scientific literature and involve appropriate professionals in the decision making process.

Disclosure
Ind. Code Ann. § 27-13-15-1 (West 1998) – gag clauses/nonretaliation – HMO contracts with providers may not prohibit disclosure of incentives to limit services or treatment options and may not penalize providers for disclosure.

Emergency Care
Ind. Code Ann. §§ 27-13-1-11.7, 27-13-36-9 (West 1998) – emergency care – HMOs must pay for emergency care without prior authorization and without regard to contractual relationships, based on prudent layperson standard.

Formularies
*Ind. Code Ann. § 27-13-38-1 (West 1998) – formularies/nonformulary drugs and devices – HMOs may use formularies, but only if (a) the formularies are developed, reviewed, and updated in consultation with and with the approval of a committee with a physician majority, and (b) there is an expeditious process for an enrollee to obtain  a medically necessary and appropriate nonformulary drug or device without prior HMO approval and without penalty or additional cost-sharing; HMOs may not void or refuse to renew a contract because a provider prescribed a drug or device as provided.

Miscellaneous
Ind. Code Ann. § 27-13-7-14.8 (West 1998) – mental health parity – HMO contracts may not impose aggregate lifetime limits or annual limits on coverage of services for mental illness if similar limitations are not imposed on coverage for other conditions (does not apply after 9/29/2001).
Ind. Code Ann. § 27-13-29-1 (West 1998) – DTPA – HMOs are subject to laws concerning unfair or deceptive acts or practices to the extent not in conflict with laws regulating HMOs.  (standard for most states)

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Iowa

Consumer/Patient Protections

Disclosure
Iowa Admin. Code r. 191-40.22(514B) – gag clauses – HMOs may not prohibit providers from, or punish providers for, discussing treatment options with patients, advocating for patients in UR or grievance processes, or reporting the HMO to regulators in good faith (roughly parallel provisions for PPOs at r. 191-27.2(514F) and 191-27.4(514F).

Emergency Care
Iowa Admin. Code r. 191-40.20(514B), 191-40.21(514B) – emergency care – prudent layperson standard adopted; HMOs may not deny reimbursement for emergency services solely on the grounds that services were performed by a noncontracted provider (parallel provisions for PPOs at 191-27.8(514F).

Consumer Participation
Iowa Code Ann. § 514B.7 – policy and operation – HMOs must establish a mechanism to allow reasonable representation of enrollees in matters of policy and operation.
Iowa Admin. Code r. 191-40.4(514B) (1998) – governance – “reasonable representation” requires that not less than 30 percent of the governing board members be enrollees who are not providers or associated with a provider; enrollees must be given the opportunity to nominate representatives.

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Kansas

Consumer/Patient Protections

Access
*Kan. Stat. Ann. § 40-4607 (1997) - standing referrals – health insurers (inclusive definition) must have a plan by which an insured with a life-threatening, chronic, degenerative or disabling condition or disease requiring specialized medical care over a prolonged period of time may receive a referral to a qualified specialist who will coordinate specialty care.
*Kan. Stat. Ann. § 40-3230 (1997) – continuity of care – HMOs must continue care with a terminated provider for up to 90 days where “continuation of such care is medically necessary and in accordance with the dictates of medical prudence” and the enrollee has special circumstances such as a disability or life-threatening illness.

Complaints/UR
Kan. Stat. Ann. § 40-3228 (1997) – grievances – HMOs are given certain timeframes, but the timeframe of 20 working days for the completion of an investigation appears to be infinitely extendable by the HMO.

Disclosure
Kan. Stat. Ann. § 40-4603 (1997) – gag clauses – health insurers may not prohibit or restrict providers from discussing/disclosing any medically appropriate health care information or from advocating on behalf of insureds in UR or grievance processes.

Emergency Care
Kan. Stat. Ann. §§ 40-3229, 40-4603 (1997) – emergency care – HMOs may not base denials solely on failure to receive prior authorization; health insurers may not deny coverage for care warranted by symptoms or for a screening exam and stabilizing treatment, regardless of authorization.

Prohibition on Incentives
Kan. Stat. Ann. § 40-4605 (1997) – incentive prohibition – health insurers may not employ compensation arrangements with providers that may directly or indirectly serve as an inducement to reduce or limit the delivery of medically necessary services with respect to an insured; capitation payments and other risk-sharing provisions are not considered inducements.

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Kentucky

Consumer/Patient Protections

Access
*1998 Ky. Acts ch. 496, § 28(1) – OON referrals – managed care plans must demonstrate that they offer an adequate number of accessible specialists and subspecialists, and when the specialist needed for a specific condition is not represented, enrollees have access to nonparticipating providers without prior plan approval.  (new section of subtitle 17A of KRS Ch. 304)

Complaints/UR
1998 Ky. Acts ch. 496, § 34 – UR standards – managed care plan medical directors must ensure that (a) UR denials of medical services based on medical necessity are made by a physician and (b) a procedure is implemented whereby physicians have an opportunity to review and comment on protocols.
1998 Ky. Acts ch. 496, § 43 – ombudsman – office created in the consumer protection and education division.

Emergency Care
1998 Ky. Acts ch. 496, §§ 25, 28(4), 59 – emergency care – managed care plans must cover emergency-room screening and stabilization, both in- and out-of-network, without prior authorization for use consistent with the prudent layperson standard.

Nondiscrimination
1998 Ky. Acts ch. 496, § 45 (amending § 304.14-130) – discrimination – plans will not be approved if they exclude or provide terms of coverage for HIV/AIDS that are different than those that apply to any other medical condition or, as to an individual policy, if the benefits provided are unreasonable in relation to the premium.

Provider Protections
*1998 Ky. Acts ch. 496, § 30(1) – profiling – selection or participation standards based on the economics or capacity of a provider’s practice must be adjusted to account for case mix, severity of illness, patient age and other features that may account for higher-than or lower-than-expected costs; plans may not use criteria that would allow an insurer to avoid high-risk populations by excluding providers because they treat or specialize in treating populations presenting a risk of higher-than-average claims, losses, or health services utilization.

Selected Benefit Mandates
Ky. Rev. Stat. Ann. §§ 304.17A-135, 304.38-1936 – breast cancer/HDC – health benefit plans (inclusive term) and HMOs that provide benefits for treatment of breast cancer by chemotherapy must also provide coverage for HDC with ABMT or SCT, which may not be considered experimental.
Ky. Rev. Stat. Ann. § 304.38-1937 – TMJ – health care services contracts that cover treatment of skeletal disorders must all cover medically necessary procedures for TMJ and related disorders.
1998 Ky. Acts ch. 438, § 1 – off-label uses of drugs – applies to all health benefit plans; limited to cancer; includes proviso that HMOs are not required to cover any drug excluded from a formulary for a reasons other than lack of FDA approval for the specific indication.  (new section of subtitle 17A of KRS Ch. 304)
1998 Ky. Acts ch. 476 § 1 – diabetes/outpatient supplies – applies to all health benefit plans issued or renewed after 4/9/98; coverage mandated for equipment, supplies, outpatient self-management training and education, and medications; “private third-party payors may not reduce or eliminate coverage due to the requirements of this section.”  (new section of subtitle 17A of KRS Ch. 304)

Miscellaneous
1998 Ky. Acts ch. 496, § 44 (amending § 304.17A-150) – marketing – unfair trade practices include encouraging individuals or groups to refrain from applying for coverage because of health status, claims experience, etc.

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Louisiana

Consumer/Patient Protections

Access
La. Rev. Stat. Ann. §§ 22:215.17, 2:2027, 40:2206 (West 1998) – OB/GYNs – HMOs, PPOs, etc. may not limit direct access to (participating) OB/GYNs for routine gynecological care.

Complaints/UR
La. Rev. Stat. Ann. § 22:2021 (West 1998) – UR standards – applies to HMOs; general directive that requirements and guidelines “shall not fall below the appropriate standard of care and shall not impinge upon the independent medical judgment of the treating health care provider”; timeframes include 2 working days for decision in urgent need cases (5 for elective cases); failure to timely approve or disapprove a request constitutes authorization; accreditation is evidence of compliance.
La. Rev. Stat. Ann. § 22:2022 (West 1998) – grievances – applies to HMOs; general; accreditation is evidence of compliance.

Disclosure
La. Rev. Stat. Ann. §§ 22:215.18 (West 1998) – gag clauses – MCOs may not include provisions in their provider contracts that interfere with the ability of a provider to communicate with a patient regarding his/her health care; provisions that prohibit providers from soliciting for alternative coverage arrangements for the primary purpose of securing financial gain are not affected.

Emergency Care
La. Rev. Stat. Ann. § 22:657(D)(2) – emergency care – MCO requirements concerning prospective evaluation are inapplicable to an emergency medical condition, defined to incorporate a prudent layperson standard (per (G), an enrollee who does not receive payment within 30 days of claim submission can sue to collect a penalty of double the amount of benefits due plus attorneys fees).

Prohibition on Incentives
La. Rev. Stat. Ann. §§ 22:215.19, 22:2018, 40:2207 (West 1998) – incentive prohibition – MCOs, etc. and their contracting entities may not include provisions in their contracts with providers which include an incentive or specific payment made directly to a provider or provider group as an inducement to deny, reduce, limit, or delay specific, medically necessary, and appropriate services provided with respect to a specific insured or groups of insureds with similar medical conditions; incentive plans that involve general payments, such as capitation payments, or shared-risk arrangements that are not tied to specific medical decisions involving a specific insured or groups of insureds with similar medical conditions are not prohibited.  40:2232?

Provider Protections
La. Rev. Stat. Ann. §§ 22:215.18 (West 1998) – nonretaliation – MCO retaliation against a provider solely on the basis of a medical communication is prohibited (also restrictions on lodging complaints with govermental bodies and patient advocacy).

Selected Benefit Mandates
*La. Rev. Stat. Ann. §§ 22:2004.1, 40:2208 (West 1998) – interpreters – HMOs and PPOs must provide coverage for expenses incurred by any hearing impaired enrollee for services performed by a qualified interpreter/transliterator (other than a family member) in connection with medical treatment or diagnostic consultations.
La. Rev. Stat. Ann. §§ 22:215.22, 22:2027, 40:2209 (West 1998) – breast reconstruction – HMOs, PPOs, etc. that cover mastectomies must cover reconstructive surgery.
La. Rev. Stat. Ann. § 22:215.20 (West 1998) – off-label uses of drugs – applies to all categories of insurers/plans that cover cancer treatment; limited to treatment of cancer.

Miscellaneous
La. Rev. Stat. Ann. § 46:153.3(3) – Medicaid/formulary – the department shall not establish a drug formulary that restricts by any prior or retroactive approval process a physician's ability to treat a patient with a prescription drug that has been approved and designated as safe and effective by the FDA (inclusion of drugs for cosmetic purposes and nonprescription drugs, anorexic drugs, drugs used solely for the treatment of infertility when prescribed for that purpose, cough and cold preparations, and minor tranquilizers is not mandatory).

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Maine

Consumer/Patient Protections

Access
Me. Rev. Stat. Ann. tit. 24-A, § 4303(1) – access – carriers (broad definition) offering managed care plans must provide members reasonable access to services in accordance with standards developed by the super.
Code Me. R. Ch. 850, § 7 – access – HMO applications for certification must include an access plan; access plans must include a description of the HMO’s basis for determining that the network is sufficient to meet basic health care services and how enrollees with special needs (mental retardation, mental illness, behavioral and/or emotional disturbances and developmental delays and disabilities) will be identified.
Code Me. R. Ch. 850, § 7(B)(6) – access – in any case where the HMO has an insufficient number or type of participating provider to provide a covered benefit, the carrier must ensure that the covered person obtains the covered benefit at no greater cost than if the benefit were obtained from a participating provider, or make other arrangements acceptable to the super.
Code Me. R. Ch. 850, § 7(C), (D) – access – specific standards for geographic accessibility and appointment and wait times.
Code Me. R. Ch. 850, § 7(F) – coordination of care – HMOs are not required to provide coverage for OON services more new enrollees if they are transferred to network providers without unreasonably disrupting ongoing care or treatment; HMOs must maintain a written plan for continuity of care in event of contract termination including 60 days notice to affected enrollees and provision for enrollees with special needs/at special risk.
Me. Rev. Stat. Ann. tit. 24, § 2332-G, tit. 24-A, §§ 2847-F, 4241 – OB/GYNs – parallel provisions for HMOs and other carriers; must permit qualified OB/GYNs to serve as PCPs; all group plan contracts must cover an annual exam from a physician or certified nursepractitioner or midwife without prior PCP approval.

Complaints/UR
Me. Rev. Stat. Ann. tit. 24-A, § 4303(4)(A) – grievances – carriers must have a grievance procedure that meets standards developed by the super. and includes timelines (no particular timeline mandated), provision of a written statement with reasons upon conclusion of the process, and decision making by individuals non previously involved in making the decision subject to the grievance.
Code Me. R. Ch. 850, § 89 – grievances – 2 levels of review; timeframe of 20 working days for 1st level (with possibility of extension), and 50 working days for 2nd level; right to appear in person at 2nd level, and majority of panel must be clinical peers not previously involved.
Me. Rev. Stat. Ann. tit. 24-A, § 4303(4)(B) – independent second opinion – in any appeal under the grievance procedure in which a professional medical opinion regarding a health condition is a material issue in the dispute, the aggrieved party is entitled to an independent 2nd opinion paid for by the plan from a participating provider of the same specialty (if none exists, a nonparticipating provider); applies to all carriers.
Me. Rev. Stat. Ann. tit. 24-A, § 4304 – UR – carriers must respond to provider requests for prior authorization of nonemergency services with an answer or request for further information within 2 business days; carriers may not retrospectively deny payment for a previously approved service.
Code Me. R. Ch. 850, § 8 – UR – UR programs must use documented clinical review criteria that are (a) based on published sound clinical evidence and (b) evaluated periodically to ensure ongoing efficacy; compensation may not be based on the quantity of adverse determinations rendered or include other incentives to render inappropriate review decisions; UREs must make initial determinations and give notice of them within 2 working days of obtaining all necessary information (1 working day for concurrent reviews); requirements for notices include statement of clinical rationale including criteria, phone number for assistance.
Code Me. R. Ch. 850, § 8(G) – appeals – appeals must be evaluated by appropriate clinical peer/s who were not involved in initial determination (unless appeal presents new information); notice of decision must be given within 20 working days; where standard timeframe would seriously jeopardize the life or health of a covered person or jeopardize the covered person’s ability to regain maximum function, a decision must be communicated no more than 72 hours after initiation of appeal, with continuation of service paid for by the insurer until notice in the case of concurrent review of emergency services or a previously authorized admission or course of treatment.

Disclosure
Me. Rev. Stat. Ann. tit. 24-A, § 4301 – incentive disclosure – carriers must provide prospective enrollees with a general description of methods used to compensate providers, including capitation and methods in which providers receive compensation based upon referrals, utilization or cost criteria.
Me. Rev. Stat. Ann. tit. 24-A, § 4302(1)(H) – formularies – carriers must provide prospective enrollees (and members of the public upon request) and current enrollees annually with a description of the plan that includes procedures enrollees must follow to obtain drugs subject to a formulary, if any; a description of any formulary and any cost sharing; enrollees may request additional information related to specific drugs  that are not on the formulary.
Me. Rev. Stat. Ann. tit. 24-A, § 4303(3) – gag clauses – carriers offering managed care plans may not restrict a provider from disclosing information regarding the treatment or the decision of any plan to authorize or deny services or benefits.

Emergency Care
Me. Rev. Stat. Ann. tit. 24, § 2302-B, tit. 24-A, §§ 2749-B, 2847-A – emergency care – policies may not include a provision permitting the insurer to impose a penalty for failure to notify the insurer of a hospitalization for emergency treatment.
Code Me. R. Ch. 850, §§ 5, 8(H) – emergency care – carriers must cover emergency services necessary to screen and stabilize a covered person and may not require prior authorization if a prudent layperson acting reasonably would have believed that an emergency condition existed; OON services to screen and stabilize if a prudent layperson would have reasonably believed that use of a network provider would result in a delay that would worsen the emergency; preauthorization may not be retracted absent fraud etc.
Code Me. R. Ch. 850, § 7(E) – emergency care – specialized standards must be utilized for evaluating the need for urgent or emergency services for infants and children and for individuals with chronic conditions.

Nondiscrimination
Me. Rev. Stat. Ann. tit. 24-A, §§ 2846, 4229 – HIV/AIDS – exclusion of HIV/AIDS from coverage, or coverage under more restrictive termsthan for other diseases, is prohibited.

Provider Protections
Me. Rev. Stat. Ann. tit. 24-A, § 4303(3) – nonretaliation – carriers offering managed care plans may not discipline a provider for advocating for medically appropriate health care.

Selected Benefit Mandates
Me. Rev. Stat. Ann. tit. 24, § 2320-F, tit. 24-A §§ 2745-E, 2837-F, 4234-D – off-label uses of drugs/cancer – parallel provisions for each category of insurer/plan; applies if contract/plan covers prescription drugs; limited to drugs used in the treatment of cancer.
Me. Rev. Stat. Ann. tit. 24, § 2320-G, tit. 24-A §§ 2745-F, 2837-G, 4234-E – off-label uses of drugs/HIV or AIDS – parallel provisions for each category of insurer/plan; applies if contract/plan covers prescription drugs; limited to drugs used in the treatment of HIV or AIDS.
Me. Rev. Stat. Ann. tit. 24, § 2320-C, tit. 24-A, §§ 2745-C, 2837-C, 4237 – breast reconstruction – all forms of individual and group coverage subject to HMO regulation and individual policies that cover mastectomies must also cover reconstructive surgery.
Me. Rev. Stat. Ann. tit. 24, § 2320-D, tit. 24-A, §§ 2745-D, 2837-D, 4238 – medical food coverage – HMOs and individual policies must provide coverage for formula and medical food products for persons with inborn errors of metabolism (coverage for low-protein food products may be capped at $3,000).
Me. Rev. Stat. Ann. tit. 24, § 2332-F, tit. 24-A, §§ 2754, 2847-E, 4240 – diabetes supplies – HMOs must provide coverage for equipment and self-management training to treat diabetes if certified as medically necessary by a treating physician or qualified specialist.

Miscellaneous
Me. Rev. Stat. Ann. tit. 24-A, §§ 2749-C, 2843 5-C – mental illness – individual and group health policies must provide benefits for the treatment and diagnosis of specified categories of mental illness under terms and conditions no less extensive than for physical illnesses.

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Maryland

Consumer/Patient Protections

Access
Md Code Ann., Health-Gen. § 19-705.1(d) – special needs plan – HMOs must have a written plan that, among other things, identifies any special groups of members that have unique health problems and describes community health resources and how they will be used.
Md Code Ann., Ins. § 15-112(i) , Health-Gen. § 19-706 – continuity of care – applies to all carriers (broad term); PCPs who have been terminated must continue to provide services to enrollees receiving services from them for at least 90 days after the termination notice (if enrollees request continuation after receiving notice of the termination), and carriers must pay for these services at the contract rate.
Md Code Ann., Ins. § 15-816, Health-Gen. § 19-706 – direct access to OB/GYNs – insurers, service benefit plans and HMOs must classify an OB/GYNs as a PCP or, if the OB/GYN declines, allow a woman direct access for routine gynecological care if the care is medically necessary and the OB/GYN communicates/confers with the PCP

Complaints/UR
Md Code Ann., Ins. §§ 15-10A-01, 15-10A-02 – grievances – carriers must establish a grievance process that includes an expedited procedure for “emergency cases” (definition to be established by IC) that provides for decision within 24 hours; otherwise the carrier has 30 working days to render a decision in prospective cases; content of notice of adverse decision is specified, e.g., specific factual bases for decision in clear, understandable language, reference to specific criteria and standards (use of generalized terms specifically prohibited); carrier cannot escape responsibility by delegating UR function.*
Md. Code Ann., Ins. §§ 15-10A-02(d), 15-10A-03, 15-10A-05 – independent review – complaints may be filed the IC without exhausting internal review processes if the complaint demonstrates a compelling reason (IC to identify circumstances); otherwise, member/provider may file complaint for review of a grievance decision within 30 days of receipt; carriers must provide any information requested by the IC no later than 7 days after receipt of request; expedited procedure for emergency cares to involve decision within 24 hours, otherwise timeframe for review is 30 working days for pending cases and 45 working days for retrospective cases; carriers have the burden of persuasion that their adverse decisions and grievance decisions are correct; qualifications for reviewers specified.
Md. Code Ann., Ins. §§ 15-10B-01 et seq. – private review agents – also regulated; final determinations on appeals must be made by a physician or panel with a physician who is not compensated in a manner that provides a financial incentive directly or indirectly to deny or reduce coverage; notice content requirements similar to those for internal review; 10C concerns certification of medical directors.
Md. Code Ann., Ins. §§ 15-10A-02(f) – ombudsman – health advocacy unit will assist consumers with filing a grievance, and carriers must notify members of availability of service in response to initial contact about an adverse decision.
Md. Code Ann., Ins. § 15-10A-04(c)(3) – criteria – it is an independent violation if the IC, in consultation with an independent review organization, medical expert, the department, of other appropriate entity, determines that the criteria and standards used by an HMO to conduct UR are not (i) objective; (ii) clinically valid; (iii) compatible with established principles of health care; or (iv) flexible enough to allow deviations from norms when justified on a case by case basis.
Md Code Ann., Ins. § 15-122, Health-Gen. § 19-706 – experimental treatments – carriers must (a) disclose definitions of “experimental medical care”; (b) establish or contract to provide a systematic, scientific process to follow for evaluating emerging medical and surgical treatments to ensure that subscribers have access to the latest appropriate treatments, to include a comprehensive literature and data review and input from qualified, independent physicians and other recognized experts; (c) base coverage decisions on the consensus of opinion from its own analysis and knowledge provided via the required process.

Disclosure
Md Code Ann., Ins. § 15-121, Health-Gen. § 19-706 – incentive disclosure – enrollment sales materials must include disclosure in layman’s terms of reimbursement methodologies used to reimburse physicians and the distribution of each $100 received in premium dollars, including the proportions for direct medical care expenses and for plan administration.
Md Code Ann., Ins. § 15-116, Health-Gen. § 19-706 – gag clauses – carriers may not prohibit health care providers from discussing with anyone any information that is necessary or appropriate for the delivery of health care services (does not affect p