WASHINGTON-Three big nonprofit HMOs have asked the government to regulate 18 ways that plans cover patients’ lives.
Kaiser Permanente, HIP Health Insurance Plans, and Group Health Cooperative of Puget Sound have joined with the American Association for Retired Persons and Families USA to demand “legally enforceable” national consumer-protection standards.
The standards are needed to restore confidence in HMOs, said Dr. David Lawrence, chairman and CEO of Kaiser Foundation Health Plan and Hospitals.
The plans also hope to deter more congressional efforts to regulate managed care by procedure or body part. Though the groups proposed neither how the standards should be enforced nor how much it all could cost, they said the rules might be incorporated into accreditation standards.
Hailed by the AMA and other physician groups, the proposed standards drew a chilly response from the American Association of Health Plans, which prefers a voluntary approach.
The principles would require plans to give access to physicians 24 hours a day, provide external review of experimental treatment denials, cover a prudent layperson’s definition of ER care, and disclose information on benefits, grievance procedures, and loss ratios. They’d let members switch primary-care physicians and allow some exceptions to drug formularies. And they’d put a lid on gag rules and on withhold schemes that induce undertreatment.
The goal is to provide minimum basic standards on which the existing patchwork of state managed-care laws could be superimposed. Many principles are already standard or pending in federal legislation. But others raise difficult issues. The groups, for example, would mandate a choice of plans, though that’s usually decided by employers, not plans. -Christina Kent
WASHINGTON-Three big nonprofit HMOs have asked the government to regulate 18 ways that plans cover patients’ lives.
