So, You're Not Happy with Your HMO?

If you're not happy with your HMO, you're not alone.

But, just how much are you willing to pay to get the services you want and deserve?

That's the question before the Legislature this year. The House and Senate agree, the HMO system has to change, to protect consumers, if nothing else. But change is going to cost you something, so we're trying to balance cost with protections.

Last year, the House passed HMO reforms, as did the Senate. But they were different bills. And the conference committee--three Senators and three Representatives chosen to iron out the differences--couldn't find enough common ground, so the bill died. We, and I say "we" because I was on that committee, were disappointed, but we were just too far apart on too many issues.

The three of us on the House side of the committee have filed a new bill for 1999. Representative Paul Haley, who is chair of Ways and Means, along with Representative Harriett Chandler, chair of the Health Committee, and myself, all hope that we can be successful in getting you the services and protections you want. At, an affordable cost.

Our legislation addresses a variety of area, including:

Emergency rooms. Managed care organizations would be required to pay for emergency room care sought for physical or mental emergencies, using the "prudent layperson" standard. If you think you're having a heart attack, if you're in severe pain, if you think you're in serious jeopardy, your insurance company would have to pay. Even if it turns out your fears were unwarranted.

After the emergency room. You'd have to get authorization for post-stabilization services. But, if the health care organization doesn't reply to a request within 45 minutes, authorization is deemed approved.

Reviews. If your HMO doesn't provide you with the services you think you deserve, from a specialist for example, or the prescription you want, you would be able to appeal. Each insuror would have to have a documented process to review its decisions, and people making those decisions at the review stage couldn't be compensated for making adverse determinations. And if your HMO still says no, you'd have the right for an external appeal. All appeals would have to be handled on a timely basis, as laid out in the legislation.

Costs of reviews. You have to pay to play. Pay $50 for an external review, which could be waived for extreme financial hardship. The state pays for the rest. But, if the HMO had declined to provide a serve, and was overruled on external appeal, then the HMO would have to reimburse you.

Disclosures. There are a lot of them. But, basically, upfront, before you sign up, you have to be told what the HMO will pay for when it comes to medical services, including prescriptions and medical devices. There will also be report cards, outlining consumer satisfaction, or dissatisfaction, how many physicians disenrolled during the previous year, and the number of grievances and appeals on record. The state would also provide an annual report of all HMOs each year.

Physicians. No HMO would be allowed to offer a physician compensation that would put the doctor at financial risk for providing treatment. Neither could they disenroll a doctor involuntarily for providing those services. And, if your doctor's services are terminated by the HMO, you can still see the same physician, with the HMO picking up the bill, if you're in your third trimester of pregnancy or are terminally ill.

Standing referrals. If you need a specialist, say a rheumatologist, or neurologist, on a regular basis, a standing referral will be made, so you don't have to ask permission to seek care from them for each visit. And, a woman can choose to have her obstetrician or gynecologist be her primary care provider.

Hospital stays. The attending physician, not the HMO, shall make all decisions on medical treatment, including length of hospital stays. It was, by the way, arbitrary decisions by HMOs that forced the legislature in the past two years to ban so-called drive-through deliveries and drive-through mastectomies.

There's more, of course. And the bill has yet to be printed or numbered, let alone debated. Or amended.

But there will be hearings before the Health Committee and Insurance Committee before the legislation goes to the House or Senate for action. So there's time for your input and, if you like, your testimony.

This is legislation to protect you, so let your voice be heard now.

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