You asked for a description of pro-patient managed care laws enacted in other states, particularly those that relate to provider access.

SUMMARY

Pro-patient managed care laws can generally be split into two categories: access to providers and consumer assistance. The “access to providers” category includes laws regarding (1) point-of-service provider selection, (2) network adequacy, (3) direct access to an obstetrician/gynecologist (ob/gyn), (4) direct access to specialists, (5) freedom of choice, (6) any willing provider, (7) any willing class of provider, (8) continuity of care, and (9) standing referrals. “Consumer assistance” laws feature (1) ombudsman programs, (2) managed care report cards, and (3) managed care plan quality assurance programs. This report describes the various pro-patient laws and lists the states that have enacted them.

Of these laws, Connecticut does not have statutes on (1) point-of-service provider selection, (2) network adequacy, (3) any willing class of providers, (4) continuity of care, (5) standing referrals, and (6) managed care plan quality assurance programs. Two of Connecticut’s managed care laws are limited in scope (i. e. , the direct access to specialists law relates to pain management specialists only and the any willing provider law applies to pharmacies only).

ACCESS TO PROVIDERS

Point-of-Service (19 States)

A point-of-service (POS) plan is one that permits enrollees to choose a non-participating provider instead of a participating provider at the time services are needed. Usually a higher copayment or a deductible will apply if a non-participating provider renders services. A POS law mandates that managed care plans provide a point-of-service choice to enrollees. This is often accomplished by providing a health maintenance organization (HMO) plan alongside an indemnity plan. If the enrollee uses a provider who participates in the HMO network, then HMO benefits apply. If he instead uses a non-participating provider, the indemnity benefits apply. POS plan rates are generally higher than HMO-only rates to compensate for the out-of-network coverage.

POS-mandate requirements vary by state. For example, some states require a POS offering only for employers with more than 25 or 50 employees or health plans with more than 5,000 or 10,000 enrollees (Minnesota, Montana, Oklahoma, Oregon, South Carolina, Tennessee, and Texas). Some states have special provisions that apply to dental plans (Alaska, Arkansas, Indiana, Maryland, and Texas). In Illinois, the point-of-service law applies only to dental plans. Connecticut does not have a POS law.

Nineteen states have POS laws: Alaska, Arkansas, Georgia, Idaho, Illinois, Indiana, Iowa, Maryland, Minnesota, Montana, New Jersey, New York, Oklahoma, Oregon, South Carolina, Tennessee, Texas, Virginia, and Wisconsin (Source: National Conference of State Legislatures, NCSL).

Network Adequacy (17 States)

A network adequacy requirement mandates that plans establish standards for the creation and maintenance of provider networks that are sufficient in numbers and types of providers to assure that managed care plan enrollees can access necessary services without unreasonable delay. Sufficiency may be determined in terms of provider-to-enrollee ratios, geographic accessibility, waiting time for appointments, and office hours. Connecticut does not have a network adequacy law.

Enclosed is a copy of the National Association of Insurance Commissioners (NAIC) Managed Care Plan Network Adequacy Model Act (NAIC 74-1).

Seventeen states have network adequacy requirements (either statutes or regulations): Colorado, Florida, Illinois, Kansas, Maine, Missouri, Montana, Nebraska, New Hampshire, New York, North Carolina, Oklahoma, Oregon, Rhode Island, South Dakota, Washington, and Wisconsin (Source: NAIC).

Direct Access to OB/GYNs (38 States)

Concerned that managed care plan “gatekeeper” primary care physician (PCP) requirements interfere with the relationship between a woman and her obstetrician/gynecologist (ob/gyn), numerous states have enacted direct access to ob/gyn laws, which give women the right to obtain services from an ob/gyn without a PCP referral. Connecticut law requires plans to give female enrollees direct access to ob/gyns (CGS § 38a-530b).

Thirty-eight states provide women with direct access to ob/gyn services: Alabama, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Idaho, Illinois, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nevada, New Hampshire, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, South Carolina, Texas, Utah, Vermont, Virginia, Washington, West Virginia, and Wisconsin (Source: NCSL).

Direct Access to Specialists (22 States)

Similarly, concerned with a gatekeeper PCP requirement’s impact on an enrollee’s access to specialists, states have enacted laws permitting direct access to specialists, meaning no referral or prior authorization is needed before receiving specialist services. While some states permit direct access to medical specialists in general, other states limit application to certain practitioners, such as chiropractors and eye-care providers. Connecticut law permits direct access to pain management specialists (CGS § 38a-518i).

Twenty-two states provide direct access to specialists: Alabama (eye-care provider), Alaska (chiropractor), Arizona (chiropractor), Arkansas (eye-care provider), Colorado (eye-care services), Connecticut (pain management specialist), Florida (dermatologist), Georgia (dermatologist), Illinois (chiropractor), Indiana (an appropriate participating provider),

Kentucky (chiropractor), Maine (eye-care provider and chiropractor), New Hampshire (chiropractor), New Jersey (medical specialist), New Mexico (medical specialist), New York (medical specialist), North Carolina (medical specialist), Oregon (emergency eye-care services), Pennsylvania (medical specialist), Texas (medical specialist), Washington (chiropractor), and West Virginia (eye-care services) (Source: NCSL).

Freedom of Choice (23 States)

Freedom of choice laws generally preserve a managed care enrollee’s right to select any available provider in the network. Many states limit these laws to providers of pharmaceutical services. Connecticut HMO law prohibits any person’s interference with another’s freedom to choose a healing arts practitioner (CGS § 38a-180). “Healing arts” refers to the licensed professions and occupations of medicine and surgery, chiropractic, natureopathy, podiatry, nursing, dentistry, optometry, opticians, and psychologists (CGS § 38a-175(1)).

Twenty-three states have a freedom of choice law: Alabama (pharmacy), Alaska (chiropractic), Connecticut (healing arts), Delaware (pharmacy), Florida (independent pharmacy), Georgia (pharmacy), Idaho (pharmacy), Iowa (pharmacy), Kentucky (chiropractic), Louisiana (pharmacy), Maryland (pharmacy), Mississippi (pharmacy), Montana (pharmacy and numerous other providers), New Jersey (pharmacy), North Carolina (pharmacy), North Dakota (pharmacy), Oklahoma (podiatrist, psychologist, clinical social workers), South Carolina (pharmacy), South Dakota (pharmacy), Tennessee (pharmacy), Texas (pharmacy), Virginia (pharmacy), and West Virginia (primary care provider) (Source: NCSL).

Any Willing Provider (22 States)

Any willing provider (AWP) laws require managed care plans to grant network participation to any provider willing to join and meet network requirements. Most states with this requirement limit its application to pharmacies, pharmacists, or both. In Connecticut, a prescription reimbursement program administrator cannot prohibit a pharmacy from enrolling in the program except for cause, including previous fraudulent use of program identification cards (CGS § 38a-471(f)).

The courts overturned Louisiana’s AWP law as being preempted by the federal Employee Retirement Income Security Act of 1974 (ERISA) (CIGNA Health Plan of Louisiana, Inc. v. State of Louisiana, 82 F. 3d 642 (1986)).

Twenty-two states have AWP laws: Alabama, Arkansas, Connecticut, Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Kentucky, Massachusetts, Minnesota, Mississippi, New Hampshire, New Jersey, North Carolina, North Dakota, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming (Source: NCSL).

Any Willing Class of Provider (37 States)

Any willing class of provider (AWCP) laws prohibit managed care plans from discriminating against particular types of providers based on their academic degrees. To do this, the laws typically broaden the definition of physician to include such practitioners as dentists, dental hygienists, optometrists, podiatrists, chiropractors, mental health practitioners, and nurse practitioners. Connecticut does not have an AWCP law.

Thirty-seven states prohibit discrimination between various classes of providers: Alabama, Alaska, Arizona, Arkansas, Colorado, Florida, Illinois, Indiana, Iowa, Kansas, Kentucky, Maine, Michigan, Minnesota, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, North Carolina, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, and Wyoming (Source: NCSL).

Continuity of Care (36 States)

Continuity of care laws address the issue of a provider that ceases participation in a managed care plan’s network. For enrollees who are undergoing treatment by a provider at the time of the provider’s network termination, such a law requires plans to continue coverage for treatment rendered by that provider for: (1) pregnancy, (2) acute illness, or (3) chronic illness (e. g. , those that are life-threatening, degenerative, or disabling). Typically the laws require that plans extend in-network coverage for 60 or 90 days generally; in the case of pregnancy, through the completion of postpartum care; and for terminal illness, for the remainder of the individual's life. The laws often allow plans to condition such continued coverage on the provider agreeing to accept the payment rates under his prior agreement and adhering to the plans' quality standards, policies, and procedures. Connecticut does not have a continuity of care law.

Thirty-six states have a continuity of care requirement: Alaska, Arizona, Arkansas, California, Colorado, Delaware, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, New Hampshire, New Jersey, New York, North Carolina, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Vermont, Virginia, Washington, West Virginia, and Wisconsin (Source: NCSL).

Standing Referrals (29 States)

Standing referral laws require managed care plans to establish procedures by which an enrollee with a life-threatening, chronic, degenerative, or disabling disease who requires specialized care over a prolonged period of time is given an ongoing authorization to receive appropriate treatment from a specialist (i. e. , a “standing referral). Connecticut does not have such a law.

Twenty-nine states have a standing referral requirement: Alaska, Arizona, California, Colorado, Delaware, Florida, Hawaii, Illinois, Kansas, Kentucky, Maine, Maryland, Massachusetts, Minnesota, Missouri, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, South Carolina, Utah, Vermont, Virginia, Washington, West Virginia, and Wisconsin (Source: NCSL).

CONSUMER ASSISTANCE

Ombudsman Programs (17 States)

Laws that create managed care ombudsman programs typically require that the state provide assistance to consumers by providing information about selecting a health care plan, enrollee rights and responsibilities, and filing complaints and appeals. Connecticut law regarding the Office of Managed Care Ombudsman begins at CGS § 38a-1040.

Seventeen states have an ombudsman program: California, Colorado (Medicaid recipients only), Connecticut, Florida, Illinois, Kentucky (Medicaid recipients only), Maine, Maryland, Massachusetts, Montana (mental health services only), New Jersey, North Carolina, Rhode Island, Texas, Utah, Vermont, and Virginia (Source: NCSL).

Managed Care Report Cards (24 States)

In an effort to provide consumers with standardized information about competing managed care plans, some states have enacted laws requiring a state agency to issue “report cards” that help the consumers select a plan in which to enroll. In other states, a report card is not mandated, but a state insurance department or other agency issues one. Connecticut law requires the insurance department to distribute annually a report card concerning all licensed HMO and the 15 largest health care insurers (by premiums written) that use provider networks (CGS § 38a-478l).

Twenty-four states produce a managed care report card, but not all are legislated to do so: California, Connecticut, Florida, Iowa, Kansas, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Missouri, New Jersey, New Mexico, New York, Oklahoma, Oregon, Rhode Island, Tennessee, Texas, Utah, Vermont, Virginia, Washington, and Wisconsin (Source: NCSL).

Managed Care Plan Quality Assurance Programs (18 States)

Concerned with the level of quality care provided by managed care plans, various states have passed laws or regulations requiring plans to implement quality assurance programs that monitor, evaluate, and initiate actions to improve health promotion activities and indicators (e. g. , use of preventive care services such as immunizations, screenings, and prenatal care). State requirements are often based upon the nationally recognized Health Plan Employer Data and Information Set (HEDIS) standards developed by the National Committee for Quality Assurance (NCQA). Connecticut does not have a law requiring a managed care plan to implement a quality assurance program.

Eighteen states mandate managed care quality assurance: Arkansas, Colorado, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana, Maryland, Massachusetts, Missouri, New Jersey, New Mexico, Oklahoma, Oregon, Texas, Virginia, and West Virginia (Source: NCSL).

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