NCPA - National Center for Policy Analysis

Managed Care Patients Already Have a Bill of Rights in Most States

February 14, 2002

A managed care backlash in recent years has led some members of Congress to propose a so-called "patient bill of rights" to protect patients from abuse by managed care and Health Maintenance Organizations (HMOs). But enrollee complaints about restricted access to care and lack of recourse when they have grievances have already been met with a variety of new state regulations protecting patients.

Each year, the Blue Cross Blue Shield Association performs a yearly audit of all state health insurance regulations. The 2001 edition illustrates how much protection patients already have:

  • Forty-three states grant patients direct access to specialists.
  • Forty-two states currently have external grievance review.
  • Nearly half of all states require managed care plans to offer a point-of-service option -- allowing plan members to use other providers -- for those employees who may not want managed care.
  • About one in eight allows a right to sue and an equal number require use of a standard definition of "medically necessary" services the plan must cover.

Many states (one-third) even require HMOs to pay non-participating providers to ensure patients' freedom of choice.

However, states often differ in their application of protections. Of the 43 states with external reviews, 13 only review "medically necessary" denials of care while eight review all claims of denial. In addition, the entity that selects the reviewer varies from state to state. Some states (4) select the reviewer while in other states (28) an independent entity selects the reviewer. Around two-thirds of the states with external review require the opinion of the external reviewer to be binding on the parties involved.

Source: Susan S. Laudicina, Betsy Losleben and Natasha Walker, "State Legislative Health Care and Insurance Issues, 2001 Survey of Plans," Blue Cross Blue Shield Association, December 2001 (released February 14, 2002).


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