patients' bill of rights act

AACAP State Patients’ Bill of Rights Update October 2002 The following is a description of state legislative provisions aimed at granting greater rights to patients regarding their medical care. This list is updated, to the best of our knowledge, as of October 10, 2002. If you have any information regarding patients’ rights legislation in your state, please contact Mary Crosby at 202-966-7300 ext. 127 or mcrosby@aacap.org. State Name Alabama Legislative Provisions Standing referrals for ongoing care with a specialist; direct access to providers (including eye care professionals); external review process (applies to any HMO). Direct access to providers (including chiropractic professionals); point-of-service safeguards for patients with an HMO insurance plan; external review process (applies to any managed care organization). Standing referrals for ongoing care with a specialist; direct access to providers (including chiropractic professionals); external review process; health plan liability. Direct access to providers (including optometrist/opth.). External review process (applicable to any health care service plan); includes liability provisions; standing referrals for ongoing care with a specialist. Direct access to providers (includes eye care professionals); access to emergency care; standing referrals for ongoing care with a specialist; external review (applies to any health plan). Direct access to providers (including pain management specialists); external review (applies to any health plan); Managed care must make payment decisions based on what is “appropriate and medically necessary” Legal Remedy Provisions Alaska No right to sue. Arizona Right to sue a managed care company. Arkansas California No right to sue Colorado No right to sue. Connecticut No right to sue. 1 State Name Delaware District of Columbia Florida Georgia Hawaii Legislative Provisions Insurers must provide at least 60 days notice before terminating or not renewing a contract with a health care provider; also, standing referrals for ongoing care with a specialist; external review (any health carrier). External review (applies to any health plan); standing referrals for ongoing care with a specialist; direct access to providers (specialist can be designated as primary care physician when condition warrants). Standing referrals for ongoing care with a specialist; external review (applies to HMOs); direct access to providers. Direct access to providers (including dermatologists); external review (applies to any managed care plan); health plan liability. Standing referrals for ongoing care with a specialist; external review process (applies to any managed care plan). None. Passed Managed Care Reform and Patients’ Rights Act, including provider protections, continuity of care, provider communications, independent appeals, and utilization review. Provisions also include: external review process; standing referrals for ongoing care with a specialist (up to one year). Point-of-service provisions; external review (applies to all HMOs); direct access to providers (specialists can be designated as primary care physician when condition warrants). External review (applies to all health insurers). Legal Remedy Provisions No right to sue insurer. No right to sue. Idaho Illinois No right to sue. No right to sue. Indiana No right to sue. Iowa No right to sue. 2 State Name Kansas Kentucky Louisiana Maine Maryland Massachusetts Legislative Provisions External review (applies to all health plans); standing referrals for ongoing care with a specialist (allows specialist to coordinate care within their scope of practice). External review (applies to all health insurers); standing referrals for ongoing care with a specialist (up to 1 year); direct access to providers (including chiropractic professionals). Patients’ rights legislation passed that establishes payment requirements; includes “medical necessity review requirements and administrative treatment guidelines.” Legislation mandates external review (applies to all health insurers). External review process (applies to all health insurance); standing referrals for ongoing care with a specialist (allows specialist to coordinate care within their scope of practice); direct access to providers (including chiropractic, eye care professionals); health plan liability. Patients’ Bill of Rights Act passed that includes standing referrals if insurers do not allow direct access to specialists; external review (all health insurers). Patients’ rights legislation passed that includes: 1) confidentiality; greater protection of sensitive medical information; 2) limits on the amount of information that can be revealed by providers or health plans; 3) an oversight board; and 4) an Office of Patient Protection. Also, standing referrals for ongoing care with a specialist. Legal Remedy Provisions Right to sue in cases of bad faith or involved negligence, gross negligence, or intentional misrepresentation of factual information about the covered person’s medical condition. No right to sue. No right to sue. 3 State Name Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico Legislative Provisions Legal Remedy Provisions No right to sue Coverage for prescription drugs within certain guidelines; external review (applies to all health insurers); direct access to providers (including pediatricians). External review (applies to any health plan reg’d by the state Insurance Commissioner); standing referrals for ongoing care with a specialist. None. External review (applies to any health carrier); standing referrals for ongoing care with a specialist (allows specialist to coordinate care within their scope of practice). None. No right to sue Health carriers and providers must give at least 60 days notice before terminating a contract without cause. None. Legislation passed to establish committee to study mental health care treatment under HMOs; external review (applies to any health carrier); direct access to providers (including chiropractic professionals). External review (applies to any health carrier); direct access to providers (at discretion of HMO, specialist may be designated as primary care physician); health plan liability. Department of Health and Senior Services sponsored nation’s first statewide survey of consumer satisfaction with mental health under HMOs. External review (applies to any managed health care plan); standing referrals for ongoing care with a specialist; direct access to providers (specialists can be designated as primary care physician when condition warrants). 4 State Name New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Legislative Provisions External review (applies to any health care service plan); standing referrals for ongoing care with a specialist (allows specialist to coordinate care within their scope of practice); direct access to providers (specialist can be designated as primary care physician when condition warrants). External review (applies to any health insurer); standing referrals for ongoing care with a specialist (up to 12 months); health plan liability. When making utilization review determinations, physicians and psychologists must have current licenses from state Board of Medical Examiners and state Board of Psychologists Examiners. External review (applies to any health insuring corporation); standing referrals for ongoing care with a specialist. External review (applies to any health benefit plan); standing referrals for ongoing care with a specialist (allows specialist to coordinate care within their scope of practice); health plan liability. External review (applies to any carrier or organized delivery system); standing referrals for ongoing care with a specialist; direct access to providers (including emergency eye care). Patient confidentiality; preauthorization not required for emergency visits; allows 60 days transitional coverage when switching plans; treatment decisions must be made for medical and not financial reasons. External review (applies to any managed care plan); direct access to providers (including OB/GYN. Also, specialists can be designated as primary care physician when condition warrants). Legal Remedy Provisions Insurer liability legislation was amended to a study of the status of health care and MCO liability. No right to sue. No right to sue. 5 State Name Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Legislative Provisions External review (applies to decisions made by review agent). External review (applies to any health carrier); point-of-service legislation passed. Standing referral for ongoing care with a specialist (dermatology). Continuity of care; gag clause ban; patient confidentiality; and intermediary contracts. Legislation passed requiring state-approved grievance system. Point-of-service protection; external review (applies to any HMO); standing referrals for ongoing care with a specialist (up to 12 months); direct access to providers (specialist can be designated as primary care physician when condition warrants). External review (applies to any HMO); direct access to providers (specialist can be designated as primary care physician when condition warrants); health plan liability. External review (applies to any health plan); standing referrals for ongoing care with a specialist. External review (applies to any health plan); standing referrals for ongoing care with a specialist. Point-of-service legislation and Fair Business Practices Act passed. External review (applies to any health plans); standing referrals for ongoing care with a specialist (allows specialist to coordinate care within their scope of practice). External review (applies to any health carrier); standing referrals for ongoing care with a specialist; direct access to providers (including chiropractic professionals); health plan liability. Legal Remedy Provisions Insurer liability legislation was amended to a study of the status of health care and MCO liability. No right to sue. No right to sue. No right to sue. Includes the right to sue and joint negotiation (an antitrust reform that allows physicians to stand up to HMOs). No right to sue. No right to sue. No right to sue. 6 State Name West Virginia Wisconsin Wyoming Legislative Provisions External review (managed care plans); standing referrals for ongoing care with a specialist; direct access to providers (including limited eye care for diabetics); health plan liability. External review (applies to any health plan); standing referrals for ongoing care with a specialist. None. Legal Remedy Provisions G:\USERS\CHRISTIN\STATE LEGISLATIVE INFORMATION\State PBR Update 2002 References: 50 State Comparisons – Kaiser Family Foundation State Health Facts Online. http://www.statehealthfacts.kff.org/ National Health Law Program http://www.healthlaw.org Families USA http://www.familiesusa.org/html/managedcare/mngedcare.htm Prepared by the American Academy of Child and Adolescent Psychiatry Department of Government Affairs Mary Crosby, Director, Deputy Executive Director, Nuala Moore, Assistant Director Christine Broderick, Legislative Assistant 3615 Wisconsin Avenue, NW, Washington, DC 20016, 202.966.7300 (telephone), 202.966.1944 (fax) 7