Blue Cross and Blue Shield Association finds legislatures easing up on mandates The push by state legislators to mandate that health plans offer specific benefits and use specific clinical practice standards eased somewhat in 1997, according to the Blue Cross and Blue Shield Associations annual report on state health legislation trends. In 1996, 30 states passed laws mandating 48-hour maternity stays for vaginal deliveries. Mandatory hospital stays for women undergoing a mastectomy appeared likely to be the next big wave of health plan legislation to sweep across the nation. But in 1997, only 14 states passed laws requiring a minimum hospital stay for women undergoing a mastectomy. In fact, last year several states decided to defer action on mandates for coverage of services such as prostate cancer screening and breast reconstruction surgery until information was available on the financial impact of these mandates. Virginia, Kansas, Wisconsin, Pennsylvania and South Carolina now have mechanisms in place to assess the fiscal impact of state mandates. Last year, Virginia legislators declined to act on requiring minimum hospital stays for mastectomy patients, and mandating coverage for reconstructive breast surgery, acupuncture, prostate cancer screening and hemophilia services. Instead, legislators referred bills to a special advisory commission set up several years ago to do cost-benefit analyses of mandates. Legislators are now reviewing that panels recommendations. Louisiana, too, passed legislation which requires submission of a cost-impact report before any bills proposing mandates make it to the floor. That action was taken after lawmakers passed, and the governor signed, several bills mandating coverage for emergency care, prostate cancer screening, diabetic self-management training, and off-label use of drugs for cancer treatment. Blues State Services Research Director Susan Laudicina said that given the political appeal of these measures she doesn't expect them to completely evaporate from the legislative hoppers this year. The lure of mandated benefits will continue in 1998 because they appear to offer a simple solution to anecdotal health problems and involve limited government expenditures, the report says. Ms. Laudicina said trends indicate, however, that politicians are beginning to think twice before rushing to legislate by disease or body-part. Health plans surveyed by the Blues for its 1997 report say that mandates on practice and coverage are boosting premiums from 5 to 20%. Other pressures on plans as a result of state legislative action include bans on gag clauses in contracts and requirements that enrollees have direct access to specialists and access to emergency room care. Politicians are beginning to think twice before rushing to legislate by disease or body-part. Laudicina Twenty four states enacted bills in 1997 barring health plans from prohibiting or restricting physicians and other providers from discussing certain treatment options with their patients. Although a 1997 General Accounting Office analysis of 500 HMOs concluded that none had contracts with gag clauses, today some 39 states have laws banning their use. Meanwhile, 14 states passed laws requiring direct access to specialists. Nine (AR, DE, ID, MN, MO, MT, NV, RI, and TX) were designed to make it easier for women to use their obstetrician/gynecologist as a primary care provider but several other provider groups got special notice as well. Florida legislators passed a law allowing direct access to dermatologists; Georgia and South Carolina now allow direct access to ophthalmologists; and, in New Mexico, patients wanting to see an acupuncturist don't need to go through their primary care doctor anymore. Plans expect a flurry of similar proposals allowing enrollees to self-refer to health care specialists in 1998. States to watch: (CA, CO, FL, IL, IN, ME, MO, MS, NE, OK, PA, SC, TN, VT, and WA. Initial screening exams Twenty states enacted laws requiring initial screening exams and stabilization services and other services be covered and delivered in an emergency room. Twelve states (CT, GA, ID, LA, MO, NV, NC, OH, OR, TX, VA, and WA) also are requiring that coverage be allowed in emergency cases deemed such by a prudent layperson. Mental health parity laws also topped legislative agendas in 1997. Eight states passed laws designed to put mental health coverage on an equal footing with physical health coverage. But many of these laws were limited. Colorado, Connecticut and Texas, for example, now require health plans to offer equivalent or similar coverage only for patients with serious, biologically based mental health illness. Laws passed in Indiana and North Carolina only apply to the state employee health plan. But plans are expecting legislators to take up these measures again in1998; 19 states are expected to introduce legislation on mental health parity this year. One of the newer areas of managed care regulation involves the establishment of external or independent grievance processes to review coverage and claims denials. Nine states, including Connecticut and Missouri, passed these laws last year. Ohio and California have the most restrictive, limiting outside review to only those appeals that involve experimental treatments. Most of the other states allow for external review of any denial. Vermont only allows external review of mental health care treatments. In 1998, 14 states (CA, DE, FL, GA, HI, MD, MS, NH, ND, NY, OK, PA, VT, and WA) and the District of Columbia will push to enact mandatory external grievance review laws. States took measures last year to bring their insurance market laws into conformance with the federal Health Insurance Portability and Accountability Act of 1996. The majority of states said they will be seeking a federal waiver to set up or use alternative state mechanisms to ensure portability to individuals moving from group to individual coverage. High-risk insurance pools were the most popular alternative mechanism, with 21 states choosing this route. Several states (FL, GA, NM, OH, PA, UT, and VA) have devised other approaches to conform with HIPAA's group-to-individual portability requirement. Georgia created an assigned-risk mechanism, under which individuals can apply for coverage to the insurance commissioner who assigns eligible persons to health plans based on a formula. Utah is using both its high risk pool and its existing guaranteed issue requirement in the individual market to ensure portability. Individuals denied coverage by a health plan are referred to the state's high risk pool, which determines whether the person is eligible. If an individual is found to be too healthy, the health plan has to provide coverage. For-profit conversion laws Gretchen Babcock, executive director of state services at the Blues, said despite moves by Blues plans in New York and Colorado to convert to for-profit status, she doesn't think there is feverish activity and that it's a major trend. Still, 10 states passed for-profit conversion laws last year intended to protect the public's interest in the assets of tax-exempt organizations. Blues plans are much more interested in merging among themselves or affiliating with other providers such as hospitals, she said. Last year, 10 states passed laws regulating merger and acquisitions and consolidations. Janet Firshein For copies of State Legislature Health Care and Insurance Issues, 1997 Survey of Plans, contact the Blue Cross and Blue Shield Association at 202-626-4780.