Best from the States: The Text of Key State Hmo Consumer Protection Provisions

Front Cover
Geraldine Dallek
DIANE Publishing, 1998 - Health maintenance organizations - 78 pages
Looks at 12 key HMO consumer protection issues and provides the actual text of the best provisions of different states' laws which address these issues. Addresses: access to, and provision of, emerg. serv.; use of specialists as primary care physicians and access to appropriate speciality care; adequacy of provider networks; continuity of care following enrollment and contract termination; access to experimental and investigational proced.; utilization review/referral systems; HMO internal quality assur. plan; data reporting; provider financial risk arrange.; disclosure of info.; grievance/appeal protections; and provider protections.
 

What people are saying - Write a review

We haven't found any reviews in the usual places.

Common terms and phrases

Popular passages

Page 70 - Making, publishing, disseminating, or circulating, directly or indirectly, or aiding, abetting or encouraging the making, publishing, disseminating or circulating of any oral or written statement or any pamphlet, circular, article or literature which is false, or maliciously critical of or derogatory to the financial condition of an insurer, and which is calculated to injure any person engaged in the business of insurance.
Page 6 - emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in — (A) placing the patient's health in serious jeopardy, (B) serious impairment to bodily functions, or (C) serious dysfunction of any bodily organ or part.
Page 34 - The policies and procedures to ensure that all applicable state and federal laws to protect the confidentiality of individual medical records are followed...
Page 31 - ... employees or affiliates, or (iv) the development or manufacture of the drug, device, procedure or other therapy which is the subject of the final denial of a claim. The impartial health entity shall not be a subsidiary of, nor owned or controlled by, a health plan, a trade association of health plans, or a professional association of health care providers. There shall be no liability on the part of and no cause of action shall arise against any officer or employee of an impartial health entity...
Page 30 - ... accompanied by copies of any permissions to reproduce published material, to use illustrations or report information about identifiable people, or to name people for their contributions. SEPARATE STATEMENTS Definition of a peer-reviewed journal A peer-reviewed journal is one that has submitted most of its published articles for review by experts who are not part of the editorial staff. The number and kind of manuscripts sent for review, the number of reviewers, the reviewing procedures, and the...
Page 72 - D. Whenever a provider voluntarily terminates his contract with a carrier to provide health care services to the carrier's enrollees under a health benefit plan, he shall furnish reasonable notice of such termination to his patients who are enrollees under such plan. E. A carrier may not deny an application for participation or terminate participation on its provider panel on the basis of gender, race, age, religion or national origin. F. 1. For a period of at least...
Page 10 - ... disease that is (i) life-threatening, degenerative, or disabling and (ii) requires specialized medical care over a prolonged period of time. Within the treatment period authorized by the referral, such specialist shall be permitted to treat the individual without a further referral from the individual's primary care provider and may authorize such referrals, procedures, tests, and other medical services related to the initial referral as the individual's primary care provider would otherwise...
Page 12 - If a health maintenance organization determines that it does not have a health care provider -with appropriate training and experience in its panel or network to meet the particular health care needs of an enrollee, the health maintenance organization shall make a referral to an appropriate provider, pursuant to a treatment plan approved by the health maintenance organization in consultation -with the primary care provider, the non-participating provider and the enrollee or enrollee's...
Page 10 - ... individual. The plan shall have a procedure by which an individual who has an ongoing special condition may, after consultation with the primary care physician, receive a referral to a specialist for such condition who shall be responsible for and capable of providing and coordinating the individual's primary and specialty care related to the initial specialty care referral. If such an individual's care would most appropriately be coordinated by such a specialist, the plan shall refer the individual...
Page 73 - ... provides to the health care professional a written explanation of the reasons for the proposed contract termination and an opportunity for a review or hearing as hereinafter provided. This section shall not apply in cases involving imminent harm to patient care, a determination of fraud, or a final disciplinary action by a state licensing board or other governmental agency that impairs the health care professional's ability to practice.

Bibliographic information