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Structuring Health Insurance Markets

Assuring Health Plan Accountability

Managed Care Standards


Jack Ehnes, Commissioner, Colorado Division of Insurance.

Molly Raphael, Deputy Secretary for Quality Assurance, Pennsylvania Department of Health, Harrisburg, PA.

Building on the concept of "functional" regulation introduced previously, this session focused on the National Association of Insurance Commissioners' (NAIC) approach to assuring that health plans are accountable to consumers and providers with whom they contract.

These components take the form of five model acts, including the following:

  • Utilization Review (UR) Model Act. Establishes a process, including time frames for initial UR decisions and for standard and expedited appeals of UR decisions. Requires use of documented clinical review criteria and appeals to be decided by clinical peers.
  • Grievance Procedure Model Act. Provides for two levels of standard reviews, as well and an expedited review process were the normal time frames may jeopardize the patient's health
  • Network Adequacy Model Act. Requires managed care plans to maintain provider networks with sufficient numbers and types of providers to assure services are accessible without unreasonable delays. Sets forth provisions that must be included in providers contracts, including an "anti-gag" clause, and a consumer "hold-harmless" clause.
  • Quality Assessment and Improvement Model Act. Requires managed care plans to measure the quality of health services provided, prepare a written assessment plan, implement it and make findings available to providers and enrollees.
  • Credentialing Verification Model Act. Directs carriers to do an initial verification and re-verity professional credentials at least every 3 years. Gives provider the right to review, correct, and supplement this information.


Ehnes J. Federal Legislation Relating to Health Care Quality. Testimony of the National Association of Insurance Commissioners' Special Committee on Health Insurance. Committee on Labor and the Human Resources of the United States Senate. March 24, 1998.

The Benefits Association. Side-by-Side Summary of The Patient Access to Responsible Health Care Act (PARCA), The Health Care Information, Consumer Protection and Quality Improvement Act of 1997, The Presidential Advisory Commission on Consumer Protection and Quality Consumer Bill of Rights. Washington D.C.: Association of Private Pension and Welfare Plans.

Advisory Commission on Consumer Protection and Quality in the Health Care Industry. November 1997. Consumer Bill of Rights and Responsibilities: Report to the President of the United States.

Health Policy Economics Group, Price Waterhouse LLP. The Impact of Managed Care Legislation: An Analysis of Five Legislative Proposals From California. The Henry J. Kaiser Family Foundation. November 1997. (summary).

Butler PA. Managed Care Liability: An Analysis of Texas and Missouri Legislation. The Henry J. Kaiser Family Foundation. November 1997. (summary).

Iglehart JK. Interview: State Regulation of Managed Care: NAIC President Josephine Musser. Health Affairs 16(6):36-43.

Havighurst CC. Perspective: Putting Patients First: Promise or Smoke Screen? Health Affairs 16(6):123-5.

Hellinger FJ. Any Willing-Provider and Freedom of Choice Laws: An Economic Assessment. Health Affairs 14(4):297-302.

Hellinger, FJ. The Expanding Scope of State Legislation. Journal of the American Medical Association 276(13):1065-70.

Jones DA. Putting Patients First: A Philosophy in Practice. Health Affairs 16(6):115-20.

Mariner W. State Regulation of Managed Care and the Employee Retirement Income Security Act. New England Journal of Medicine 335(26):1986-9.

NGA Center for Best Practices. February 20, 1998. State Strategies to Improve Managed Care Quality and Oversight in a Competitive Market. Issue Brief. Washington D.C.: National Governors' Association.

Zelman, WA. Consumer Protection in Managed Care: Finding Balance. Health Affairs 16(1):158-66.

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