INSURANCE Health Care Plans: Provide for Certification of Managed Health Care Plans; Mandate Disclosure of Information to Enrollees; Mandate a Grievance Procedure for Enrollees Denied a Claim; Bar Plans from Paying Physicians Who Give Less Than Appropriate Care or Penalizing Physicians Who Advocate Appropriate Care for Their Patients

This Act is known as the Patient Protection Act of 1996. The Act encourages physicians to advocate appropriate care for their patients. Under the Act, a managed care plan must obtain a certificate from the Commissioner of Insurance before offering coverage to State residents, and the Commissioner may terminate the certificate for violations. Mandatory standards for certification include disclosure to enrollees and applicants of the precise nature of the services and benefits available under the plan, copayments, any reviews of care that could result in denial of coverage, the names of physicians who accept the coverage, a grievance procedure for denied claims and a summary of the outcomes of grievance procedures, the availability of emergency services, whether the plan restricts the availability of prescription drugs (referred to as formulary restriction), and access to additional information about the plan. The plan must provide reasonably prompt care twenty-four hours a day, must pay for emergency services and out-of-area services, and must establish a quality assurance (QA) program. The QA program must, among other things, stress health outcomes, have written protocols, provide review by physicians, and detect underutilization and overutilization. The plan may not use financial incentives that compensate a physician for providing less than appropriate care. Furthermore, a plan may not penalize a physician who discusses appropriate care with or on behalf of his patient. The plan must have procedures to safeguard patient privacy. The plan must provide, without prior authorization, for emergency services to stabilize a patient; the patient may not be transferred to another facility unless the treating physician certifies that the patient is stable