Politics & policy

Insight into federal and state health care legislation & CMS regulation

Managed Care Reform Hot Topic Nationwide; Maryland, Virginia Consider Appeals Rights

We'll hear a lot about state-level managed care reform this year. Many states are considering bills that, in several respects, mirror aspects of consumer protection measures now under debate in Washington, D.C. Maryland and Virginia could be the next states to strengthen the rights of patients who appeal health coverage denials. And in Maryland, legislators may soon consider whether to increase the roles of physicians in the appeals process.

This session, the Maryland General Assembly is expected to consider a proposal giving the state insurance commissioner authority to resolve coverage disputes after a plan's internal appeals procedure had run its course. The commissioner would be allowed to consult third-party physicians before making a determination. The bill would apply only to HMOs — not to other types of managed care plans. A similar proposal failed to pass last year.

Maryland's bill could also contain language designed to allow nurse practitioners to contract directly with HMOs. That would overrule a decision by the insurance commissioner barring such an arrangement. Commissioner Steven Larsen ruled in November that while advanced-care nurses can perform many of the same functions as doctors, HMOs must contract with a physician, who then may hire a nurse practitioner to provide primary care. He cited state law that requires patient care to be under physician management.

Nurse practitioners counter that another state law prohibits HMOs from discriminating against providers who practice as their licenses allow. Under Medicare and Medicaid rules, nurse practitioners can operate independent of physician supervision.

In Virginia, Health Commissioner Randolph Gordon is trying to revise the state's appeals process by moving it from the insurance department to the health department. Currently, HMOs send cases for appeal to an independent medical expert hired by the plans. Under Gordon's proposal, the health department would hear the appeal, removing any appearance of a conflict of interest.

Subscribe to Our Newsletters

Monthly table of contents

Be notified as each issue of Managed Care is available online.

Biweekly newsletter

Recent topics have included:

  • Doug Jones and the ACA, Epic misses a White House meeting, and man caves for man-flu sufferers
  • CVS-Aetna deal may trigger merger mania, Johns Hopkins criticized for lack of asthma prevention, & Columbia sees free-ride future for all of its med students

PTCommunity news

New drug approvals, clinical trials, drug management. Three times per week.


2018 Year in Preview
By Susan Ladika
2018 Year in Preview
By Thomas Reinke