HHS Issues New Patients’ Rights Rules for Medicaid Beneficiaries in Managed Care Plans
The Bush administration yesterday issued new patients' rights protections for Medicaid beneficiaries in managed-care plans, guaranteeing them a grievance process, access to a second opinion and coverage for emergency care, the Wall Street Journal reports. The new rules were mandated by the Balance Budget Act of 1997, which allowed Medicaid beneficiaries to join HMOs (Lueck, Wall Street Journal, 6/14). About 58% of Medicaid beneficiaries belong to managed care plans. HHS Secretary Tommy Thompson yesterday said the rules would give Medicaid beneficiaries enrolled in HMOs the same types of protection that participants in private plans would receive under patients' rights legislation being considered by Congress. Under the new rule, which is published today in the Federal Register and becomes effective Aug. 13, Medicaid will:
- Pay for emergency room care "whenever and wherever the need arises";
- Allow beneficiaries access to a second opinion (HHS
- Address beneficiaries' grievances within 45 days, with the possibility of a two-week extension;
- Complete the grievance process in three working days for patients "whose life or health is in jeopardy," with the possibility of a two-week extension (Wall Street Journal, 6/14);
- Allow women "direc[t] access" to a woman's health specialist for routine and preventive health services;
- Not establish restrictions, including "gag rules," that interfere with patient-provider communications;
- Approve marketing materials used by HMOs to enroll beneficiaries and prohibit door-to-door and telephone marketing; and
- Require HMOs to provide beneficiaries with "comprehensive, easy-to-understand information" about the plan.
States and health plans must comply with the rules within one year (HHS release, 6/13). The Journal reports that the Bush administration rules "scale back considerably" the standards written by the Clinton administration but never enacted. Under those rules, HMOs would have had 30 days to resolve grievances and 72 hours for an expedited grievance (Wall Street Journal, 6/14). The final regulation is available online. This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.