State Laws

Nineteen states have POS laws. Point-of-service (POS) plans permit enrollees to choose a nonparticipating provider instead of a participating provider at the time services are needed. A higher copayment or a deductible may apply if a non-participating provider renders services. A POS law mandates that managed care plans provide a point-of-service choice to enrollees. This is often accomplished by providing a HMO plan alongside an indemnity plan. If the enrollee uses a provider who participates in the HMO network, then HMO benefits apply, but the indemnify benefits apply if a non-participating provider is used. State laws vary. Some require a POS offering only for employers with more than 25 or 50 employees or health plans with more than 5,000 or 10,000 enrollees Others might have special provisions that apply to dental plans.

Seventeen states have network adequacy requirements. Such laws mandate that plans establish standards for the creation and maintenance of provider networks that are sufficient to assure that managed care plan enrollees can access necessary services without unreasonable delay. Sufficiency may be determined in terms of provider-to-enrollee ratios, geographic accessibility, waiting time for appointments, and office hours.

Twenty-three states have a freedom of choice laws that preserve a managed care enrollee’s right to select any available provider in the network. Many states limit these laws to providers of pharmaceutical services.

Twenty-two states have AWP (any willing provider) laws that require managed care plans to grant network participation to any provider willing to join and meet network requirements. Most states with this requirement limit the application to pharmacies or pharmacists.

Thirty-seven states prohibit discrimination between various classes of providers based on their academic degrees. To do this, the laws typically broaden the definition of physician to include such practitioners as dentists, dental hygienists, optometrists, podiatrists, chiropractors, mental health practitioners, and nurse practitioners.

Thirty-six states have a continuity of care requirement. These address providers that cease participation in a managed care plan’s network. For enrollees who are undergoing treatment by a provider at the time of the provider’s network termination, continuity of care requires continued coverage for treatment rendered by that provider for (1) pregnancy, (2) acute illness, or (3) chronic illness (e. g., those that are life-threatening, degenerative, or disabling).

Twenty-nine states have a standing referral requirement. These require managed care plans to establish procedures by which an enrollee with a life-threatening, chronic, degenerative, or disabling disease who requires specialized care over a prolonged period of time is given an ongoing authorization (a standing referral) to receive appropriate treatment from a specialist.

Thirty-eight states provide women with direct access to ob/gyn services.

Twenty-two states provide direct access to specialists.

Seventeen states have an ombudsman program.


Inside State Laws