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State by State Guide to Managed Care Law, 2018 Edition

State by State Guide to Managed Care Law, 2018 Edition

By John F. Buckley IV


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State by State Guide to Managed Care Law simplifies and expedites your research by giving you immediate access to key court decisions, state managed care policies and practices, and extensive citations to codes and regulations - for all 50 states. Identify your issue in the index and turn to the page indicated.

You'll find current, authoritative information that can help you to:

  • Evaluate baseline quality standards
  • Determine when managed care enrollees have access to providers
  • Establish guidelines for collection and disclosure of financial information
  • Arm yourself to tackle the complicated issue of prescription drugs
  • Ensure that the managed care organization recognizes patients' and providers' due process rights

Previous Edition: State by State Guide to Managed Care Law, 2017 Edition, ISBN 9781454871330

Last Updated 01/08/2018
Product Line Wolters Kluwer Legal & Regulatory U.S.
ISBN 9781454883920
SKU 10044985-0002
Table of Contents

1. Managed Care Organizations in General

  • Definition of “Health Maintenance Organization”
  • HMO Alternatives and Variations
  • Administrative Requirements for Group HMOs
  • Financial Requirements
  • Taxation of HMOs
  • Genetic Discrimination Prohibitions

2. Access to Providers

  • The Any-Willing-Provider Rule
  • Point of Service
  • Direct Access to Obstetrician/Gynecologist; Assignment as a Primary Care Physician
  • Direct Access to Medical Specialists; Designation of Medical Specialists as Primary Care Providers
  • Freedom of Choice
  • Continuity of Care
  • Standing Referrals
  • Any Willing Class of Providers

3. Access to Coverage

  • Emergency Service Mandates
  • Inpatient Care After Childbirth
  • Inpatient Care Following a Mastectomy
  • Clinical Trials
  • Newborn/Dependent Coverage
  • Mental Health Coverage Mandates

4. Pharmaceutical Issues

  • Off-Label Drugs and Drug Formularies Under Managed Care
  • Narrow Therapeutic Index Drug Laws
  • Generic Therapeutic Substitutions by Pharmacist
  • Mandatory Coverage of Prescription Contraceptives
  • Requirements for Coverage of Drugs and Prostheses

5. Grievances and Appeals

  • Definition of “Medical Necessity”
  • Independent External Review
  • HMO Liability

6. Provider Contract Issues

  • Bans on the Use of Financial Incentives and Gag Clauses
  • Prompt Payments to Providers
  • Prohibitions on “Hold Harmless” Clauses
  • Bans on “All Products” Clauses
  • Collective Negotiation

7. Provider Protections

  • Provider Termination
  • Whistleblower Protections

8. Consumer Assistance and Information

  • Ombudsman Programs
  • Managed Care Report Cards
  • Managed Care Plan Quality Assurance Program Mandates

9. Licensing of Medical Directors and Utilization Review Directors

  • Requirements for Medical Directors of HMOs

10. Continuation and Conversion Coverage

  • Continuation and Conversion Requirements

Appendix - State HMO Acts