US Managed Care Laws for Ombudsman, Report Cards and Provider Profiles Resources in United States

US Managed Care Laws for Ombudsman, Report Cards and Provider Profiles Resources

Partly revised and reposted: November 2007

A trend begun about eight years ago within the larger HMO and managed care policy debate focused on provisions to make managed care work better. (See the State Legislatures magazine article “Making the Best of Managed Care” 6/01.) Four types of laws emerged that particularly fit the theme “making it work.”  The legislation examined include:

1. Ombudsman or consumer assistance offices – State-funded but independent offices that act directly on behalf of a patient unable to get needed medical care or other services.
2. Consumer report cards – Widely published, easy-to-read reports that compare all the major competing managed care health companies for quality, finances and services.  See Rand Study, 2006
3. Provider and doctor profiles – Easy to get public records with details about doctors so consumers can spot strengths such as training and credentials as well as cautions such as medical board sanctions or malpractice judgments.  This approach has been widely adopted by individual Medical Boards, in many cases without legislative or regulatory requirements.  Most programs apply to all situations, not just those related to managed care or insurers.
4. Right to a second medical or surgical opinion – Nine states formally mandate the option to obtain a second opinion, with costs covered by insurance.   These states are CA, MD, MN, MO, NJ, NY, RI, WV & WI.

Note: law citations in blue are web links; (parentheses) indicate annual bill numbers. (Statute citations are updated through 2006)

* Although MN does not have legislation requiring the state to report managed care performance, the state does produce a report under Minnesota Statues § 62D.08, which requires managed care organizations to provide information to the state.