North Carolina Gov. Mike Easley signed a patient’s bill of rights bill into law today (10/18), making his state the 46th to give more legal power to health care consumers. State officials say the new measure is the toughest in the country. Even so, without congressional action on the issue, up to one-third of Americans are not helped by state managed care laws.
That’s because most employer-sponsored health plans are regulated by the federal employee Retirement Security Act, or ERISA, and are exempt from the state mandates.
There’s no gold standard for a patient’s bill of rights, but measures typically require HMOs to tell patients what services are paid for and let women have direct access to an OB/GYN without a referral.
Patients also get the right to air complaints and challenge refusals to pay for care. California was the first state to enact a patient’s bill of rights in 1994.
To date,
- 48 states prohibit health plans from telling doctors what they can and cannot say to patients,
- 47 states require plans to pay for emergency care,
- 41 states give women direct access to an OB/GYN, and
- 40 states have an appeals process for patients to use if they’re not happy with a doctor’s decision.
North Carolina officials looked at other state laws and pending federal bills before deciding what its bill of rights would look like.
“We extracted the strongest provisions of all the measures and we even added a few new ones,” says Alan Hirsch, policy director for Gov. Easley, who unveiled the legislation last February with lawmakers.
Policymakers decided, for instance, to give doctors more say in prescribing drugs. Right now, many health plans restrict drugs they’ll pay for by putting them on a list known as a formulary.
Under North Carolina’s new law, “if a doctor believes a particular drug is needed by a patient, he has the ability to prescribe it” even if it’s not on the formulary, says Hirsch.
Hirsch says in crafting the measure, there wasn’t a lot of discussion about potential congressional action. “We’re not too terribly concerned that Congress would enact a bill that would lower patient protections. We’re reasonably confident our law will stand,” he says.
States are concerned about what will happen to laws already on the books, since some congressional proposals will weaken state mandates.
“The federal patients bill of rights is weaker than most of what the states have, and federal lawmakers don’t want to invalidate some of the really good stuff states have done,” says Rachel Morgan of the National Conference of State Legislatures.
“The biggest impact on states is whether they’ll be required to have existing laws certified or whether the feds will grandfather them in,” she says.
There are currently two versions of patient protection bills pending in Congress, so it’s unclear whether state laws will be grandfathered in or whether they’ll have to undergo federal certification. Morgan says full-fledged certification would require the federal government to create a new agency to review what states have done. “It’s a guessing game until Congress gets something in black and white,” she says.
| STATE | YEAR ENACTED | PROVISIONS |
| Alaska | 1998 | Ban on gag clauses, direct access, bans financial incentives |
| Arizona | 2000 | Grievance procedures, direct access, experimental treatment |
| Arkansas | 1997 | Inpatient care after childbirth, mastectomies, provider credentialing |
| California | 1994 | Information disclosure, emergency care services, appeals |
| Colorado | 1997 | Consumer grievance process, ER, prescription mandates |
| Connecticut | 1997 | Ban on gag clauses, grievance process, medical records, ER |
| Delaware | 1998 | Bans financial incentives, grievance process, network adequacy |
| Florida | 1997 | Ban on gag clauses, grievance process, data collection, direct access |
| Georgia | 1996, 1999 | Disclosure, grievances, confidentiality, independent appeals |
| Hawaii | 1998 | Ban on gag clauses, ER care, independent review |
| Idaho | 1997 | Direct access, emergency care, out-of-network providers |
| Illinois | 1999 | Ban on gag clauses, consumer assistance, emergency care, appeals |
| Indiana | 1998 | Ban on gag clauses, grievances, medical records, drug formularies |
| Iowa | 1999 | Disclosure, emergency care, independent appeals, report cards |
| Kansas | 1997 | Ban on gag clauses, grievance process, ER, direct access |
| Kentucky | 1998, 2000 | Grievance process, ER, medical records, direct access |
| Louisiana | 1997 | Consumer grievances, financial disincentives, quality assurance |
| Maine | 1996, 2000 | Disclosure, reporting, credential, ban gag clauses, ER, experimental treatment |
| Maryland | 1995 | Oversight of plans, certification standards |
| Massachusetts | 2000 | External review, ER, grievance process, mandated kids mental health services |
| Minnesota | 1997 | Ban on gag clauses, disclosure, ER, medical records |
| Mississippi | 1995 | Certification standards only |
| Missouri | 1997 | Ban gag clauses, data collection, direct access, ER, medical records |
| Montana | 1997 | ER, access, provider selection, ban gag clauses, premium rate restrictions |
| Nebraska | 1998 | Ban gag clauses, grievance process, ER, network adequacy |
| Nevada | 1997 | Ban gag clauses, disclosure, ER, financial disincentives |
| New Hampshire | 1997 | Consumer grievance, ban gag clauses, medical records, network adequacy |
| New Jersey | 1997 | Ban gag clauses, grievance process, financial incentives |
| New Mexico | 1997, 1998 | Ban gag clauses, grievance process, network adequacy |
| New York | 1996 | Disclosure, grievance process, direct access, quality of care |
| North Carolina | 2001 | Grievance process, Rx formulary |
| North Dakota | 1999 | Ban financial incentives, ER, whistleblower protections |
| Ohio | 1997 | Consumer grievance process, ER, network adequacy, genetic testing |
| Oklahoma | 1997, 1999 | Referrals, ER, ban gag clauses, quality of care, consumer grievances |
| Oregon | 1995, 1997 | Consumer grievances, ER, disclosure, network adequacy |
| Pennsylvania | 1998 | Ban gag clauses and financial incentives, consumer grievance |
| Rhode Island | 1996 | Certification, disclosure, confidentiality, ban gag clauses |
| South Carolina | 1998 | Ban gag clauses, disclosure |
| South Dakota | 1999 | Network adequacy, quality of care, ban gag clauses, register managed care plans |
| Tennessee | 1998 | OB/GYN access, eye care, network adequacy, formularies |
| Texas | 1997 | Ban gag clauses, consumer grievance, ER, quality of service |
| Vermont | 1996 | Annual review, disclosure, ban gag clauses, quality assurance |
| Virginia | 1995, 1996, 1998, 1999 | Appeals, emergency care, ban gag clauses, medical records |
| Washington | 1996, 2000 | Disclosure, ban gag clauses, consumer grievance, direct access |
| West Virginia | 2001 | Disclosure, financial incentives ban, second medical opinion, grievances |
| Wisconsin | 1998 | Emergency care, gag clauses, director certification, experimental treatment |
SOURCE: National Conference of State Legislatures
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