Patient Protection

Managed care patient protection laws aim to ensure quality and access to care for patients in managed care organizations (MCOs), including:

  • Any-willing provider (AWP) laws are state statutes requiring MCOs to accept any provider who is willing to accept the plans terms and conditions (i.e. give the same discount as offered by the preferred provider).
  • Continuity-of-care laws allow patients to continue seeing their provider for a period of time after the provider leaves the managed care network. These laws may also allow new patients joining a health plan to continue seeing their providers for a period of time even if that provider is not a member of the plan network. Some state regulations only provide these continuity-of-care protections to patients with very serious conditions, such as pregnancy, terminal or severe chronic illnesses.
  • External review laws create a review process for coverage denials that is independent from the health plan, in contrast with internal grievance or appeal procedures.
  • Drug formularies are lists of medications that a payor (usually the insurer) will cover as a benefit. Decisions about what medications are included on formularies are usually made by medical experts and are based on clinical and scientific information. Some states have set limits on the use of such formularies.
  • Another practice used by health plans to contain costs is the use of financial incentives to reward providers for cost savings. The nature of these financial incentives varies depending on the type of plan and contract used. For example, increasingly more and more physicians are sharing financial risk with MCOs through capitation of payments. Some states have set limits on the use of such incentives.
  • In the absence of substantial federal patient’s rights legislation many states legislatures have enacted their own patient protection laws. Concerns addressed in these laws are similar to those addressed by federal legislation: access to specialty care, coverage for cancer treatments, holding HMOs liable for denial of coverage decisions, and barring financial incentives for providers to deny, reduce, or delay medically necessary care.

The Duke Center for Health Policy has developed a draft working paper that summarizes the benefits and costs of managed care patient protection regulation.

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