Health Policy --Federal Issues

Health Policy --Federal Issues
Health Policy Tracking Service

Any Willing Provider

Almost half the states have laws prohibiting health insurers from excluding participation of willing and qualified health care providers in their geographic coverage areas. Although most provisions are limited to pharmacies or pharmacists, several states have adopted broad provisions applying to hospitals, physicians, chiropractors, pharmacists, podiatrists, therapists and nurses.

Typical Provisions

A typical any willing provider law requires all health insurers to be ready and willing at all times to enter into service contracts with all health care providers who are qualified under state law, who practice within the general geographic area served by the insurance company, and who are willing to meet the terms and the conditions set forth by the insurer.

Pros and Cons

Proponents argue that, by selectively contracting and thereby excluding some providers, health plans are threatening providers' freedom to practice. Because providers increasingly depend on managed health plans as a source of income, they have lobbied aggressively for laws that would obligate plans to contract with any provider who meets the terms of participation.

Opponents of the concept claim it undermines cost control mechanisms employed by health plans allowing them to offer lower premiums to enrollees.

Key Issues

In drafting legislation, the key questions that must be addressed relate to the classification of providers that should be protected by the clause and the application to health insurers.

In answer to the first question, legislation can be broad in scope, applying to all or most licensed providers in the state. It either spells out a list of providers covered by the provisions (e.g., physicians, pharmacists, chiropractors, speech therapists, podiatrists, optometrists, facilities, etc.) or asserts that the provisions apply to all providers licensed in the state without specifically listing any.

Legislation also can be limited in scope. Usually, the limited provisions apply only to pharmacies or pharmacists. In some cases, they apply to a limited number of allied professionals such as chiropractors, optometrists, psychologists and social workers.

2003 Legislative Activity

The only bills currently in consideration are in New York. Senate Bill 2823 and Assembly Bill 4439 address participation of laboratories, and Assembly Bill 1915 participation of pharmacies. None of the bills have moved from their chamber of origin.

Currently 21 states have these laws applying to specific categories of providers as follows:

Provider Categories	State Laws
Pharmacists/Pharmacies	Alabama, Connecticut, Delaware, Florida, Illinois, Indiana, Massachusetts, Mississippi, New Hampshire, New Jersey, North Carolina, North Dakota, South Dakota, Tennessee, Texas, Wisconsin
Broad Application	Georgia: The two laws apply only to Blue Cross Blue Shield contracts or rural health care providers participation in plans in their geographic regions. Defines qualifying counties. Idaho: All qualified health care providers. Illinois: Limited to participating providers with public aide. Indiana Kentucky Minnesota: Any qualified independent health care provider. Wyoming: Any qualified Wyoming provider.

In addition, Arkansas and Louisiana had any willing provider laws that had been turned over by the courts.

State

Law

Court Decision

Arkansas

Ark. Stat. Ann. @ 23-99-201

Prudential Insurance Co. of America vs. National Park Medical Center Inc, (State of Arkansas) DC EArk, No. LR-C-95-514 (1/31/97); amended (03/17/97)

The Prudential Insurance Company of America, et al., vs. the State of Arkansas, No. 97-2221/2226/2229, (9/2/98)

Louisiana

PPOs/broad-(La. R.S. 40:2202 1996))

Cigna Health Plan of Louisiana Inc. vs. the State of Louisiana, 82 F.3d 642 (4/30/96)

Murphy vs. Community Health Network of La., No. 97-CA-248, 1998 WL 265017 (La. Ct. App. May 27, 1998)

The Health Policy Tracking Service, a program of the National Conference of State Legislatures, systematically collects, tracks, analyzes and publishes information on the actions of state legislatures affecting health policy, and provides value-added services including research support and e-mail alerts. HPTS maintains a password-protected web site with access to over 300 health policy topics-categorized under Behavioral Health, Health Insurance, Medicaid, Pharmaceuticals, Providers and Tobacco-available to legislators and their staff, or by subscription to others. HPTS also produces Issue Briefs, special reports and annual publications that are available as individual purchases. For more information contact us at info@hpts.org or 202.624.3567.

For more information regarding the federal issues, contact Joy Johnson Wilson at Joy.Wilson@ncsl.org or Rachel Morgan at Rachel.Morgan@ncsl.org . Refer questions regarding state issues to Lillian MacEachern at Lillian.MacEachern@ncsl.org.