Managed Care Proposal/Program Comparison, May 1998

444 North Capitol Street, NW, Suite 515, Washington, D.C. 20001
202/642-5400; 202/737-1069 fax

May 1998

MANAGED CARE PROPOSAL/PROGRAM COMPARISON

Staff Contacts: Joy Johnson Wilson, Director, Health Committee; Steve Lewis, Policy Associate, Health Committee

Printing Tip: Set Printer to Paper Size = Legal; Orientation = Landscape

Plan Choice/Enrollment Protections	Information Disclosure	Discrimination	Access	Continuity of Care
Emergency Services	Grievance Procedures/Internal	Grievance Procedures/External	Utilization Review	Quality Assurance Programs
Privacy and Confidentiality	Protections Related to Covered Benefits	Anti-Gag Rule	Provider Protections	Minimum Solvency Requirements
Insurer Liability	Enforcement	Preemption of State Law	--	--

PROPOSAL/PROGRAM	PRESIDENT’S CONSUMER BILL OF RIGHTS	JEFFORDS (S. 1712)	NORWOOD (H.R. 1415)	DEMOCRATIC LEADERS (H.R. 3605: S. 1890)	STATE LAWS
Regulated Entities	Very broad – indemnity, MCOs, ERISA plans, Taft-Hartley trusts, church plans, association plans, State and local government employee plans, and public insurance plans.	Group health plans, including ERISA plans.	Individual plans, group health insurance, and group health plans.	Individual and group health plans, including ERISA plans.	Varies by state.
PLAN CHOICE/ENROLLMENT PROTECTIONS
Point of Service (POS) Requirements	No provision.	No provision.	Must offer POS option at time of enrollment.	Allows a limited point of service (POS) option for employees who are offered only a closed panel HMO. Requires the health plan, not the employer, to make the POS option available. Employers are not required to contribute to the POS option.	11 states require health plans to offer point-of-service options: Georgia, Idaho, Iowa, Maryland, Minnesota, Montana, New Jersey, New York, Oklahoma, Oregon, and Texas (TX is for dental plans only).
Other Provisions	None.	None.	None.	None.	21 states have freedom-of-choice laws. Alabama, Arkansas, Connecticut, Delaware, Florida, Georgia, Iowa, Idaho, Kentucky, Louisiana, Maryland, Mississippi, Montana, New Jersey, North Carolina, North Dakota, Oklahoma, South Carolina, South Dakota, Texas, Virginia.
INFORMATION DISCLOSURE
Covered and Excluded Benefits	Required.	Requires disclosure of covered benefits (including drugs contained on a formulary). Excluded benefits must be disclosed upon request.	Required.	Required.	34 states have enacted laws related to disclosure covering a wide range of provisions. 20 states require the disclosure of drugs contained on formularies. Arizona, Arkansas, Connecticut, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Michigan, Missouri, New Jersey, New York, North Carolina, Oregon, Rhode Island, Vermont, Washington, and Wyoming.
Enrollee Financial Obligations	Required.	Required.	Required.	Required.	N/A
List of Health Plan Providers	The numbers, types, board certification status, and geographic distribution of providers.	Upon request. Includes: provider’s credentials. Specialty focus of providers. Affiliation arrangements of providers. The number and mix of participating providers.	The number, mix, and distribution of participating providers; ratio of providers to enrollees.	Required.	N/A
Prior Authorization/UR Process & Requirements	Upon request.	Requires a description of prior authorization procedures. UR procedures must be available upon request.	Required.	Required.	N/A
Grievance/Appeals and UR Process/Requirements	Upon request.	Required.	Required.	Required.	N/A
Outcomes of Grievance, Appeals, and UR Process	No provision.	A description of the number of external review requests that have been filed and the outcomes of the requests in the preceding calendar year must be available upon request.	Required for outcomes of UR determinations and percentage reversed on appeal.	Required (upon request).	N/A
Quality Indicators	Required.	Required.	Required.	Required.	N/A
Enrollee Satisfaction Data	Required.	Requires participant satisfaction and disenrollment rates for the previous two years.	No provision.	Required.	N/A
Enrollee Utilization Data	No provision.	No provision.	Required.	No provision.	N/A
Provider Selection Standards	No provision.	No provision.	Required.	No provision. However, enrollees may request to see credentials of providers.	N/A
Provider Financial Incentives/Payment Methods	Provider compensation methods, including base payment and additional financial incentives.	Required upon request.	Required.	Required.	N/A
Disclosure of Utilization Criteria/Algorithms	No provision.	No provision.	Screening criteria, weighting elements, and computer algorithms in UR reviews and a description of the method by which they were developed.	No provision.	N/A
Data Standardization	Commission’s final report will address presentation of information.	No provision.	HHS/DOL regulate, including presentation of information in marketing.	Requires data to include at least: Aggregate utilization data; Demographic characteristics of enrollees; Disease and age-specific morbidity and mortality rates; Enrollee satisfaction data; and Data on quality indicators and outcomes.	N/A
Plan Loss Ratios	No provision.	No provision.	Required.	Required.	N/A
DISCRIMINATION
Anti-Discrimination Provisions	Prohibits discrimination in the delivery of health services, and in marketing and enrollment, based on race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information, or source of payment.	No provision.	No provision (deleted from original bill).	Prohibits plans from discriminating in their access to covered health care services. Prohibits plans from discriminating against their enrollees on a variety of factors including genetic information, sexual orientation, and disability. Provision does not affect the issuance or pricing of policies.	8 states have enacted legislation. In addition, HIPAA prohibits discrimination based on "health status-related" factors which includes: Health status, Medical condition, Claims experience, Receipt of health care, Medical history, Genetic information, Evidence of insurability (including conditions arising out of domestic violence), and Disability
ACCESS
Sufficient Number, Mix, & Distribution of Providers	Requires sufficient numbers and types of providers (recommend NAIC’s standards for provider network adequacy).	No provision.	Required.	Plans must have a sufficient number, distribution, and variety of providers to ensure that all enrollees receive covered services on a timely basis.	At least 10 states have enacted laws requiring access to sufficient numbers and types of providers without unreasonable delay.
Special Rules for Underserved Areas	If insufficient numbers and types of providers are available, consumers should be able to go outside the network at no extra cost.	No provision.	Telemedicine and other innovative means may be considered.	Has provision that states "qualified health care providers" may include Federally qualified health centers, rural health clinics, migrant health centers, and other essential community providers.	N/A
Enrollee Choice of Primary Care Provider	Consumer should have choice of provider within network.	No provision.	Enrollees under network coverage must be allowed to choose personal health care professional from all participating providers and change selection [as appropriate (deleted)] in the event of a disciplinary complaint against the provider or at least every 4 months.	Requires plans to permit enrollees to receive primary care from any participating primary care provider who is available to accept additional patients.	N/A
Emergency Care Access	24 hours per day, seven days per week.	24 hours per day, seven days per week.	24 hours per day, seven days per week.	No provision.	At least 8 states require ER access 24 hours per day, seven days per week. Colorado, Georgia, Minnesota, Missouri, New Mexico, New Jersey, Ohio, and Virginia.
Standard for Specialist Access	Requires access to appropriately trained specialists while maintaining the integrity of network models of care.	No provision.	Enrollees must have access when necessary, including direct access for continuation of care.	Patients with special conditions must have access to providers who have the requisite expertise to treat their condition. Allows for referrals for enrollees to go out of the plan’s network for specialty care, at no additional cost to the enrollee, if there is no appropriate provider available in the network for the covered services. Provides protections for children with special needs, including access to pediatric specialists.	N/A
Standard for Access to Specialists for Individuals with Chronic Illness	Consumers with complex and serious medical conditions who require frequent specialty care should have direct access to a qualified specialist of their choice within the network. Consumers undergoing an extensive course of treatment at the time they join a new health plan should be able to continue seeing their current providers for a period up to 90 days.	No provision.	Coordination of care or cost control programs may not create undue burden for enrollees with special health care needs or chronic conditions. A plan, in conjunction with enrollee and treating provider, must determine in these cases whether specialist or care coordinator is appropriate to ensure continuity of care.	Requires plans to have a process for selecting a specialist as a primary care provider and for accessing necessary specialty care, without impediments for individuals who are seriously ill or who require continued care by a specialist.	5 states allow individuals with chronic illnesses to have specialists as their primary care provider. Indiana, New Jersey, New Mexico, New York, and Texas.
Care by OB-GYN	Women should be able to choose a qualified provider offered by a plan—including gynecologists, certified nurse midwives, and other qualified health care providers—for the provision of routine and preventive women’s services.	No provision.	No provision.	Provides for direct access to ob/gyn care and services (1); Permits women to designate their ob/gyn as a primary care provider (2).	32 states require either direct access to OB/GYNs, OB/GYNs as primary care providers (PCP), or both. Direct access: Arkansas, Colorado, Georgia, Illinois, Minnesota, Missouri, Nevada, New York, North Carolina (Medicaid only), Rhode Island, Texas, Utah, Vermont, Virginia, and Washington. PCP: California, Florida, Indiana, Nebraska, New Jersey, and Wyoming. Both: Alabama, Connecticut, Delaware, Idaho, Louisiana, Maine, Maryland, Mississippi, Montana, New Mexico, and Oregon.
Clinical Trials	No provision.	No provision.	No provision.	Plans must have a process for allowing certain enrollees to participate in a defined set of approved clinical trials and for covering the routine patient costs associated with these trials.	No provision.
CONTINUITY OF CARE
Enrollee Protection when Provider Contract Changes	Consumers undergoing an extensive course of treatment should be able to continue seeing a provider who is terminated for reasons other than cause for 90 days or through completion of postpartum care.	No provision.	When change might disrupt continuity of care, plans must cover services furnished by the treating provider for a reasonable period of time. Includes women in second or third trimester of pregnancy.	Establishes guidelines for the limited continuation of treatment in instances where disruptions may occur due to a change in plan or in a provider’s network status.	14 states have continuity of care laws that allow enrollees to see non-participating providers when they first join a plan (for certain medical conditions) or when a provider is no longer with a plan. Arkansas, Colorado, Florida, Idaho, Indiana, Kansas, Maryland, Minnesota, Missouri, New Jersey, New York, Texas, Vermont, and Virginia.
EMERGENCY SERVICES
Coverage of Evaluation and Treatment w/o Prior Authorization	Required.	Required if emergency care is a covered service.	Required.	Required if emergency care is a covered service.	26 states require coverage. Arizona, California, Connecticut, Florida, Georgia, Idaho, Indiana, Kansas, Maine, Maryland, Minnesota, Missouri, Montana, Nevada, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Tennessee, Texas, Virginia, and Washington.
Coverage of Maintenance and Post Stabilization Care	No provision.	Must comply with Medicare+Choice standards for post-stabilization care.	No provision.	Must comply with Medicare+Choice standards for post-stabilization care.	No states.
Prudent Layperson Standard (3)	Yes, adopts the Medicare definition.	Yes, same as Medicaid definition.	Yes, same as Medicaid definition.	Yes, adopts the Medicare definition.	18 states use "prudent layperson" as defined under the Balanced Budget Act of 1997. Arkansas, Colorado, Connecticut, Georgia, Idaho, Indiana, Louisiana, Maine, Maryland, Minnesota, Missouri, New York, North Carolina, Ohio, Oregon, Tennessee, Texas, Virginia, and Washington. Another four states use variations on this definition. Arizona, California, Florida, and New Mexico.
Reasonable Payment Standard for Participating and Non-participating Providers	Non-network providers and facilities should not bill patients for any charges in excess of health plans’ routine payment arrangements.	Yes.	Yes. Includes emergency care, urgent care, medical screening and other ancillary services.	Yes. Plan must reimburse non-participating providers at same rate as participating providers if it is a covered service.	N/A
Prior Authorization Standard for Other Emergency Room (ER) Services	No provision.	No provision.	No provision (deleted coverage for urgent care).	No provision.	N/A
GRIEVANCE PROCEDURES, INTERNAL
Process	Procedures must be available to appeal decisions to deny, reduce, or terminate services or to deny payment for services. They must also be available for resolving consumer complaints about issues such as waiting times, operating hours, the demeanor of providers, and the adequacy of facilities.	Plans must establish an internal appeal process under which an enrollee, or a provider with the consent of the enrollee, who is dissatisfied with any adverse determination has the opportunity to discuss and appeal that decision.	Procedures are required for addressing adverse utilization review determinations and for other enrollee complaints of inadequate access.	Plans must maintain an internal grievance process that is expedient and conducted by appropriately credentialed individuals.	All 50 states require MCOs to have to have grievance and appeals procedures.
Timeliness Standard	Plans must provide "timely" notification for decisions to deny, reduce, or terminate services or deny payment for services. Plans must provide for expedited consideration of decisions involving emergency or urgent care consistent with the time frames required by Medicare (i.e., 72 hours).	30 days for routine determinations. 72 hours for expedited determinations.	[One hour for urgent care and 24 hours for other services (deleted).] Adverse utilization review claim disputes must be reviewed within 72 hours (new). 30 days for payment claims.	Concerns should be addressed in a timely manner. Requires the establishment of an expedited process for special circumstances.	At least 24 states require explicit timeframes. Arizona, California, Colorado, Connecticut, Delaware, Florida, Illinois, Indiana, Michigan, Missouri, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Oklahoma, Oregon, Pennsylvania, Tennessee, Texas, Utah, Vermont, and West Virginia.
Professional Qualifications of Reviewers	Health care professionals appropriately credentialed with respect to the treatment involved.	No provision.	Appropriate clinical peer professional in the same or similar specialty as would typically provide service.	Reviewers must be appropriately credentialed individuals.	At least 19 states address the professional qualifications of reviewers. Arizona, Arkansas, California, Connecticut, Florida, Indiana, Missouri, Nevada, New Hampshire, New Jersey, New Mexico, New York, Ohio, Rhode Island, South Dakota, Texas, Utah, Vermont, and West Virginia. Most states prohibit use of provider involved in prior decision.
Ombudsman Program	No provision.	No provision.	No provision.	Authorizes an ombudsman program in each state to assist consumers in understanding health insurance options, filing appeals and grievances.	N/A
Written Documentation of Adverse Determinations	Requires written notification of the final determination that includes information on the reason for the determination and how a consumer can appeal that decision to an external entity.	Written notification must be provided on how the determination may be appealed to an external entity.	No provision.	Written notification must be provided on reasons for denial and rights to any further appeal.	At least 21 states require written notification, either automatically or upon commissioner’s request. Arizona, Arkansas, California, Colorado, Florida, Georgia, Illinois, Indiana, Maine, Michigan, Nevada, New Hampshire, New Jersey, New Mexico, New York, Ohio, Oregon, Tennessee, Texas, Vermont, and West Virginia.
Maintenance of Internal Record of Process	No provision.	Plans must maintain written records with respect to any appeal for purposes of internal quality assurance and improvement.	Required for outcomes of UR determinations and percentage reversed on appeal	Plans must have a system to record and document, for at least the previous 3 years, all grievances and appeals made and their status.	Most states require some form of maintenance of internal record of process.
GRIEVANCE PROCEDURES, EXTERNAL/INDEPENDENT
Procedures	Requires plans to make available only after consumers have exhausted all internal processes, except in cases of urgently needed care. Requirement applies to any decision by a health plan to deny, reduce, or terminate coverage or deny payment for services based on a determination that the treatment is either experimental or investigational; Requirement applies when a decision is based on a determination that the services are not medically necessary and the amount exceeds a significant threshold or the patient’s life or health is jeopardized.	Plans must have written procedures that allow an enrollee to file an external appeal of an adverse determination if the determination involves treatments or services covered by the terms and conditions of the plan that cost at least $1,000.	Requires plans to make available only after consumers have exhausted all internal processes. Requirement applies to any decision by a health plan to deny, reduce, limit, or terminate coverage or deny payment for services based on a determination that the treatment is either experimental or investigational. Requirement applies when a decision is based on a determination that the services are not medically necessary and the amount exceeds a significant threshold or the patient’s life or health is jeopardized. The entire external review section is new.	Requires states and the U.S. Department of Labor (DOL) to establish an independent external appeals process for the plans under their respective jurisdictions. Requires the plan to pay the costs of the process and any decision is binding on the plan. Prohibits plans from retaliating against providers who advocate on behalf of their patients who choose to access the appeals process.	Varies among 17 states that require independent review. Usually requires exhaustion of all internal review processes first. Arizona, California, Colorado, Connecticut, Florida, Maryland, Minnesota, Michigan, Missouri, New Jersey, New Mexico, North Carolina (two out of three reviewers on the panel must be external), Ohio, Rhode Island, Tennessee, Texas, and Vermont. California is for experimental or investigational therapy decisions only. Ohio is for life expectancy under two years and other certain conditions.
Certification of Reviewer	Additional analysis must be done according to Advisory Commission	The "appropriate State Agent" must ensure that the external entity is licensed or certified to conduct external reviews.	Reviewers must have appropriate medical or clinical expertise and be licensed or certified to conduct external reviews by an appropriate State agent.	To be determined by the state and the U.S. Department of Labor.	Same as above.
Binding Process	No provision.	Decision is binding but a party may still file a civil action.	Decision is binding but a party may still file a civil action.	Decision is binding on the plan.	At least 7 states – Arizona, California, Connecticut, Missouri, Ohio, Rhode Island, and Texas. In Maryland, the Insurance Commissioner decides if whether or not the decision is binding.
UTILIZATION REVIEW
Utilization Review (UR) Program	No provision.	Required for all plans.	Required for all plans.	Required for all plans.	N/A
Applicable Standards	No provision.	No provision.	Plans must uniformly apply review criteria that are based on sound scientific principles and the most recent medical evidence.	Plans must utilize written clinical review criteria developed pursuant to the program with input of appropriate physicians.	N/A
Enrollee or Provider Input	No provision.	No provision.	Required for medical policies, UR policies, quality and credentialing activities, and medical management procedures.	Requires "appropriate physician" input.	N/A
Reviewer of Professional Standards	No provision.	No provision.	[Requires plans to use qualified health professionals for review determinations (deleted from original bill).] Peer review required for adverse determinations by professional in same or similar specialty. Prohibits financial incentives for denials.	Reviewer must be a physician or health care practitioner licensed, accredited, or certified to perform specified health services consistent with State law.	N/A
Timeliness Standard	No provision.	"Routine determinations" must be made within 15 days. "Expedited determinations" must be made within 72 hours.	[One hour for urgent care and 24 hours for other services (deleted from original bill).] 72 hours from the time of request (new). 30 days for payment claims. Prior authorization requirements are waived when access to UR personnel is not "timely" (as defined by the applicable state authority).	3 days for routine authorizations. 1 day for reauthorization of ongoing care.	N/A
Consistency Standard	No provision.	No provision.	Requires uniform application of review criteria.	Programs must be conducted consistent with written policies and procedures.	N/A
Notice or Documentation of UR Decisions	No provision.	Notice of an expedited review determination must be provided to the enrollee and the treating provider within the 72 hour period by the most expedient method available. Notice for routine determinations must be made within 24 hours after the determination is made.	Notices of determination must include an explanation of the basis of the determination, the right to an appeal, the right to an external review, and the right to be represented by counsel (new).	Enrollees and providers must be notified by telephone and in writing as soon as possible, but no later than 3 days. For adverse determinations, enrollees must be informed in writing of: The reasons for the determination; Instructions on how to initiate an appeal; and Notice of the availability of the clinical review criteria relied upon to make the determination (upon request).	N/A
Other Patient/Provider Protections	None.	None.	Favorable prior authorization determination must be treated as final for payment purposes.	No provision.	N/A
QUALITY ASSURANCE PROGRAM
Requirements	No provision.	No provision.	Quality [improvement (deleted)] assessment (new) program must be established to assess and improve enrollee health status and satisfaction, patient outcomes, care processes, and administrative and funding capacity of issuer to fund preventive care, utilization, access and availability, cost effectiveness, acceptable treatment modalities, specialist referrals, peer review. Plans must report findings to purchasers, participating health providers, and administrative personnel.	Requires plans to have a quality assurance program to monitor and improve care.	22 states have laws or regulations requiring quality assurance programs.
Data Collection	Plans must disclose	Plans must disclose a summary of the data concerning enrollee satisfaction, including disenrollment rates for the previous 2 fiscal years. Plans must also disclose a description of the quality indicators and health outcomes measures as required by the Secretary, in accordance with the recommendations made by the Health Quality Council.	Plans must analyze quality assessment data to determine specific interactions in the delivery system that have an adverse impact on the quality of care.	Plans are required to collect data in order to monitor quality of care provided to enrollees. Data must be in a standard format so comparisons can be made across plans.	N/A
Advisory Board	No provision.	Creates a "Health Quality Council" as a resource for Congress and the President by providing information on the financial and socioeconomic impact of pending legislation regarding health care quality and consumer protections. The Council would also report on quality improvements in the health care market and set national goals for improving that care.	No provision.	Establishes a public/private advisory board to advise the Secretary on the standardized minimum data set and other activities to improve health care quality.	N/A
PRIVACY AND CONFIDENTIALITY
Safeguards for Individually Identifiable Information	With very few exceptions, individually identifiable information can be used without written consent for health purposes only. In addition, disclosure of individually identifiable information without written consent should be permitted in very limited circumstances where there is a clear legal basis for doing so.	Plans must establish procedures with respect to medical records or other health information regarding enrollees to safeguard the privacy of any individually identifiable enrollee information.	Plans must establish procedures for compliance with state and federal laws.	Health plans must have appropriate safeguards to ensure confidentiality, update records in a timely and accurate fashion, and allow patients access to their records.	Most states have laws on privacy and confidentiality but they vary considerably.
PROTECTIONS RELATED TO COVERED BENEFITS
Mandated Benefit Coverage	Evaluation and treatment of emergency services.	No provisions.	Evaluation and treatment of emergency services.	See mastectomy coverage below.	Mandated benefits laws are numerous and varied. All states have mandated benefits laws ranging from a few to around 40 laws.
Drug Formularies	Plans must disclose whether a formulary is used and, if so, how decisions are made regarding the inclusion of drugs, particularly new drugs.	If a plan uses a formulary, it must disclose the specific prescription medications included.	No provision.	If a plan uses a drug formulary, the plan must: Ensure participation of participating physicians and pharmacists in the development of the formulary; Disclose to providers and to enrollees (upon request) the formulary list; and Provide for exceptions from the formulary limitation when a non-formulary alternative is medically indicated.	10 States require plans to disclose the formulary list: Arizona, Florida, Idaho, Kansas, Kentucky, Michigan, New Jersey, New York, Rhode Island, and Wyoming 11 States require disclosure and the procedure to obtain non-formulary drugs: Arkansas, Connecticut, Georgia, Indiana, Louisiana, Maine, Missouri, North Carolina, Oregon, Vermont, and Washington. Ohio requires the procedure only.
Mastectomy Length of Stay	No provision.	No provision.	No provision.	Requires plans to provide inpatient coverage for 48 following a mastectomy and 24 hours following a lymph node dissection.	15 States require a minimum length of stay following a mastectomy: Arkansas, Connecticut, Florida, Illinois, Maine, Montana, New Jersey, New Mexico, New York, North Carolina, Oklahoma, Pennsylvania, Rhode Island, Texas, and Virginia.
Post-Mastectomy Reconstructive Breast Surgery	No provision.	No provision.	No provision.	Mandates coverage of reconstructive breast surgery after a mastectomy if desired by the patient.	29 States – Arizona, Arkansas, California, Connecticut, Hawaii, Florida, Illinois, Indiana, Louisiana, Maine, Maryland, Michigan, Minnesota, Missouri, Montana, Nevada, New Hampshire, New Jersey, New York, North Carolina, Oklahoma, Pennsylvania, Rhode Island, Tennessee, Texas, Virginia, Washington, West Virginia, and Wisconsin.
Balanced Billing Limits for Out of Network Services	Prohibits balanced billing for emergency out-of-network services.	No provision.	No provision.	No provision.	For emergency care out-of-network, usually limited to standard cost-sharing. For other out-of-network services, depends on type of managed care plan.
ANTI-GAG RULE
Medical Communications Between Patient and Provider	Prohibits "gag clauses" or other contractual mechanisms that restrict health care providers’ ability to communicate and advise patients about medically necessary treatment options.	No restrictions on communication allowed.	A health insurance issuer may not prohibit or restrict a health care professional from advising a patient about the health status of the individual or medical care or treatment for the patient’s condition or disease, regardless of whether benefits for such care or treatment are provided under the coverage if the professional is acting within the lawful scope of practice (consistent with Medicare language in BBA).	Prohibits plans from "gagging" providers.	43 states ban the use of "gag clauses." The following states have not enacted laws: Alabama, Alaska, Hawaii, Illinois, Mississippi, South Carolina, and South Dakota.
Exceptions Based on Religious or Moral Considerations	Plans must disclose "matters of conscience" that could influence advice or treatment decisions.	No provision.	Plans are not required to provide, reimburse for, or provide coverage of a counseling or referral service if the plan objects to the provision of the service on moral or religious grounds.	No provision.	N/A
PROVIDER PROTECTIONS
Provider Incentive Plans	Plans must disclose methods of compensation, ownership of or interest in health care facilities that could influence advice or treatment decisions.	No provision.	Prohibited unless: (1) payments are not made as inducement to restrict medically necessary services; (2) the plan puts provider at substantial financial risk; (3) the plan provides stop-loss protection; and (4) the plan conducts periodic customer satisfaction/access surveys. The plan must provide the state or the Secretary with sufficient information to determine whether the incentive plan is acceptable.	Prohibits plans from providing incentives to providers to limit medically necessary services.	18 states ban the use of financial incentives between managed care plans and providers. California, Florida, Georgia, Idaho, Illinois, Kansas, Louisiana, Maryland, Montana, Nebraska, Nevada, New Jersey, New Mexico, Ohio, Rhode Island, Texas, Vermont, and West Virginia.
Anti-Discrimination	No provision.	No provision.	Prohibits discrimination in provider selection on basis of race, origin, gender, age, disability, or professional’s lack of affiliation with or admitting privileges at a hospital. Prohibits discrimination in participation, reimbursement, or indemnification against health professional solely on basis of professional’s license or certification under applicable state law.	Requires plans to have a written, objective process for provider selection. Prohibits discrimination based on license, location or patient base. Permits plans to limit the number and mix of providers as needed to serve enrollees for covered benefits.	N/A
Provider Contracting	No provision.	No provision.	Plans are prohibited from terminating provider contracts without cause. Plans must provide reasonable notice of decision to terminate provider for cause, an opportunity to review reasons behind the termination, and an opportunity to enter into corrective action plan before the termination becomes subject to appeal. Plans are not required to renew a contract with a participating provider (new).	Requires plans to provide reasonable notice of termination to affected providers. Providers should be permitted to review any information behind the termination decisions and to appeal adverse determinations within the plan.	24 states have laws regarding provider contracting and termination rules. Arkansas, California, Colorado, Connecticut, Florida, Idaho, Indiana, Louisiana, Maine, Maryland, Michigan, Mississippi, Missouri, Montana, Nevada, New Jersey, New York, Ohio, Oklahoma, Oregon, Rhode Island, Texas, Vermont, and Virginia.
Provider Application/Participation Requirements	No provision.	No provision.	Plans must allow all providers to apply for participation at least annually, provide reasonable notice of the application period, provide for review of applications by a committee, appropriately representing types of providers, and select providers based on objective standards. When economic considerations are used in the selection process, plans must apply them objectively, adjust any economic profiling to account for patient characteristics that could result in atypical service utilization, and disclose profiling results. Plans must offer providers an opportunity to review/correct information related to nonselection, and to appeal all adverse determinations.	No provision.	21 states have AWP laws. Five of those apply to physicians and the remainder apply primarily to pharmacies or pharmacists. Alabama, Arkansas (broad), Connecticut, Delaware, Florida, Georgia (broad; BC/BS plans only), Idaho (broad), Illinois (non-institutional providers), Indiana (broad), Kentucky (broad), Massachusetts, Mississippi, New Hampshire, New Jersey, North Carolina, North Dakota, South Carolina, South Dakota, Texas, Wisconsin, and Wyoming (broad). In addition, at least five other states have "opportunity to apply" laws, which allow providers to apply for inclusion on an MCOs panel but does require the MCO to accept all qualified providers. California, Georgia, Montana, Oregon, and Texas.
Payment Timeliness Standard	No provision.	No provision.	No provision.	No provision.	15 states require plans to pay claims to providers within a certain timeframe ranging from 30 to 60 days. Alabama (45 days), Arkansas (45), California (45), Colorado (60), Connecticut (45), Maryland (45), Mississippi (45), Montana (30), Nevada (30), New Jersey (60), New York (45), Oklahoma (30), Texas (45), Vermont (45), and Wyoming (45).
MINIMUM SOLVENCY REQUIREMENTS
Provisions	No provision.	No provision.	Insurers must meet applicable state solvency requirements and establish mechanisms required by the state to protect enrollees and health care providers from insurer failure.	No provision.	All 50 states have solvency requirements for health plans.
INSURER LIABILITY (4)
Provision	No provision.	No provision.	Amends ERISA to allow a cause of action for personal injury or wrongful death to be brought in State court against insurers or third party administrators. Specifically exempts employers provided the employer is not making medical decisions (new).	Allows state law to determine whether or not a health care beneficiary can bring a state cause of action against health plan administrators who cause harm through their actions. Employers are protected from liability when they are not involved in the decision.	Texas and Missouri have enacted insurer liability laws. The Texas law allows personal injury or wrongful death claims to be brought in State court against insurers. In Missouri, the corporate medicine law was repealed which may open health plans up to medical malpractice claims.
ENFORCEMENT
Provision	No provision.	Coordinated regulatory effort by HHS and DOL for areas not related to state authority over insurance.	Coordinated regulatory effort by HHS and DOL for areas not related to state authority over insurance.	Coordinated regulatory effort by HHS, Department of Treasury, and DOL for areas not related to state authority over insurance.	Usually the Department or Division of Insurance. CA HMOs are regulated by the Department of Corporations.
PREEMPTION OF STATE LAW
Provisions	No provision.	State enforcement of provisions for issuers. HHS Secretary can enforce if states fail to substantially enforce provisions. DOL Secretary to enforce provisions for ERISA plans.	State enforcement of provisions for issuers. HHS Secretary can enforce if states fail to substantially enforce provisions. When the Secretary is enforcing, entities in violation of act will be subject to civil money penalties up to $25,000 for each violation. DOL Secretary to enforce provisions for ERISA plans.	This Act does not preempt current State authority over insurance.	Does not apply.

(1) Direct access to ob/gyn services allows enrollees to see their ob/gyn for obstetrical and gynecological services without first obtaining a referral from their primary care provider or "gatekeeper."

(2) Laws that allow enrollees to use their OB/GYN as their primary care provider enables enrollees to see their OB/GYN for all primary care services.

(3) States that have adopted the "prudent layperson" standard do not all mandate coverage for emergency services. For example, a law may state that if a plan provides coverage for emergency care, then they must apply the "prudent layperson" standard to determine whether a particular emergency room visit is covered.

(4) The Employee Retirement Income Security Act of 1974 (ERISA) preempts individuals in employer-sponsored plans from holding health plans legally accountable for decisions to limit care that ultimately cause harm. Under current law, an injured person can only recover the dollar value of the benefit that was denied.

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