Point
of Service
Upon enrollment and at least annually thereafter, all
patients in managed care plans must have the opportunity
to choose an out-of-network ipoint-of-servicei option,
allowing them to be treated by the provider of their choice
if they are willing to assume any added costs associated
with this option.
Access
to Specialty Care
Patients must have timely access to any qualified participating
specialist with appropriate clinical expertise who is
available to accept the patient for care. If an appropriate
in-network specialist is not available, a patient must
have timely access to out-of-network specialists at
no additional cost to the patient.
Access
to Clinical Trials
Patients with chronic or life-threatening illnesses
must have access to the full range, and all phases of,
federally approved clinical trials. Any routine patient
costs incurred for items and services furnished in connection
with participation in the clinical trial must be covered
by the health plan.
Access
to Emergency Room Services
If a health plan provides emergency care coverage, then
the health plan must provide emergency care coverage
to patients for symptoms that would reasonably suggest
to an average person that their health could be at serious
risk, including severe pain. Services necessary to treat
and stabilize the patient must also be covered whenever
and wherever the need arises.
Health
Plan Accountability
Internal
and External Appeals
Patients must be afforded notice of and have the right
to both fair and timely internal and external appeals.
The plan must provide, in a manner that is easily understandable,
adequate and timely notice to the patient why coverage
has been denied and what further review or appeal options
are available. In the case of external appeals, the
review must be de novo and independent. The external
reviewer(s) must have clinical expertise in the area
in which the review is being conducted. Considerations
of medical necessity must be based on professionally
recognized standards. The finding of the external reviewer(s)
must be binding on the plan and enforceable.
Patient
Information
Information
Disclosure
Patients must be provided all information relating to
a health plan's benefits and procedures, including all
appeals processes, limitations and exclusions. In addition,
a uniform information checklist must be provided to
patients to enable them to evaluate the performance
of their health plan and its ability to provide the
full range of care.
Gag
Clauses
Gag clauses, which prohibit a provider from communicating
information to patients, including treatment options,
must be prohibited.
Financial
Incentives
Financial relationships between a health plan and a
provider that could serve as an inducement to reduce
or limit access to medically necessary services to patients
must be prohibited.
Scope
Without exception, all patients in managed care plans
must be protected by a federal law that embodies the
above-referenced principles to the extent that they
are not already protected by stronger state laws.
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