           |
| |
Four Proposals Compared
Murphy
Bill |
MCAC
Proposal |
Olasz Bills |
PMS
Proposal |
|
| Access & choice | Prohibits gag clauses & provider disincentives for care; benefits must be accessible to all enrollees; ensures continuity of care in case of provider termination from network; requires point of service option | Broadens definition of primary care physician; allows sub-contracting with non-participating specialists; prohibits gag clauses & disincentives for specialty referrals | Any willing health care provider; Any will pharmacy provider | Due process protections for network exclusions; specialty & geographic distribution of physicians must provide adequate access to care; out-of-network coverage for emergencies & when care is not available in-network; prohibits gag clauses |
| ER coverage | Subject to prudent layperson standard | Subject to prudent layperson standard | Subject to prudent layperson standard | |
| Reporting | Requires reports on cost-effectiveness, quality and solvency of MCOs | Requires reports on network exclusions and utilization review plans and utilization | ||
| Confidentiality | All patient information must remain completely confidential | |||
| Marketing | Prospective & current enrollees must be notified in writing of coverage limits and of any changes | Must provide specified information to consumers; marketing practices reviewed by Health Dept. or DPW | Notice of coverage provided by insurer must be provided to potential & current enrollees | Uniform disclosure form |
| Utilization Review | Health care decisions must be determined by licensed medical provider | Necessity or appropriateness of care can only be overturned by a licensed professional in same profession and specialty as original provider; 24-hour telephone access | Pa-licensed physicians who are in active practice and in specialty that performs care have responsibility for any final denials of coverage; mandatory certification of UROs | |
|
Bans discrimination against groups and denial of coverage mandated by civil or criminal courts | Prohibition against network exclusions of physicians who treat high severity patients | ||
| MA managed care | DPW to ensure that MCOs use excess revenues to reduce payments or increase services | Entitled to same safeguards as required for general population | ||
| Ombudsman | Under contract with Office of Consumer Advocate to investigate provider and patient complaints | UR, network exclusions and disclosures overseen by Health and Insurance departments | ||
| Grievance procedures | Timely grievance process within MCO with final appeal reaching objective third party | Requires timely response to grievances; decisions may be appealed to Health Dept. or through arbitration | HMOs must publish & distribute grievance procedures; Health Dept. toll-free number for consumer complaints | Patients entitled to participate in UR appeals |
| Cost Containment | 85% to 90% of premiums must go toward health care; HMOs must share practice profiles with participating providers |
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