Ahead Of The Feds: How Some States Are Already Regulating Managed Care

By Andrew Goldstein

While Congress debates two competing proposals to give patients a bill of rights, many states have passed their own regulations in the past several years. Those regulations can apply to only about 60% of Americans because of a 1974 federal law that exempts self-insured plans from state oversight. But Governors are lobbying hard to change that. Some of the most progressive states:

Oregon Oregon's comprehensive Patient Protection Act forces health plans to disclose the financial incentives they offer physicians to control costs, gives consumers the right to a full appeals process if denied treatment and allows access to emergency-room care.

Texas Texas, like Oregon, has its own bill of rights, and recently decided to make all HMO complaint records public. Texas is the only state in the U.S. to allow consumers to sue insurance companies if they do not use "ordinary care" in denying or delaying payment for treatment. The law is currently being challenged in court by Aetna and other insurance companies.

New Jersey Last year New Jersey published its first HMO report cards, using information HMOs are required by law to provide. The 1997 report showed that New Jersey hmos fell short of national averages when it came to preventive care such as child immunizations and screenings for breast cancer. Many hope the ratings, which let consumers compare their HMOs with others, will pressure HMOs to increase their benefits.

Maryland Maryland has possibly the largest number of health-care mandates in the U.S.; among other things, they require state-based health plans to guarantee adequate hospital stays for new mothers and to cover mental health and substance-abuse care, as well as prostate diagnostic exams for men between the ages of 40 and 75.

--By Andrew Goldstein