HEALTH CARE and HEALTH CARE APPEALS: Action to ensure a health care appeals system which protects patients, makes insurers accountable and objectively addresses patients’ concerns. (1999)
- Uniform state standards and guidelines for health care appeals. The standards and guidelines should:
a. be applicable to all health insurers not covered by federal law;
b. include time frames for responding to appeals and the qualifications required of reviewers;
c. require that professional standards be used in making decisions on appeals.
- Collection of health care data which can be used to hold health insurers accountable and which is understandable and accessible to patients.
Background: The 1997 LWVMD Convention adopted a study of “the need for state laws regarding appeals of Health Maintenance Organization/Medicaid Managed Care Organization (HMO/MCO) determinations”. The study was prompted by concerns about alleged HMO failures to provide necessary treatment, and a new project to enroll Medicaid clients in MCOs.
The Study Committee decided to broaden the scope of the study to include all health insurers because legislation introduced in the General Assembly would do just that. Legislation was passed in the 1998 General Assembly which provided rules for appeals of adverse decisions within the health insurers’ systems, and for further appeal to the Insurance Commissioner.
Members decided in consensus meetings that the 1998 law should be broadened to include all health insurers not subject to federal law (workers’ compensation and disability and long-term care insurance plans were excluded from the 1998 law, as was the Medicaid MCO program), and that data collection should be more inclusive. Data could include, for example, patients’ degrees of satisfaction with their health insurance plan, the plan’s effectiveness in providing preventive services, quality of care measures, and the number and outcome of appeals. Members agreed that other provisions of the 1998 law are adequate, pending operational experience.
- Supported various aspects of bills that would increase coverage for the uninsured and underinsured based on LWVUS positions. (2003-2006)