|
In general, a managed care program seeks to deliver quality care in a
cost effective manner to eliminate unnecessary services and to prevent
excessive, uncoordinated use of medication, radiological and other
medical services. For purposes of this table, managed care is defined as
the use of organizations or plans that combine the use of provider
groups with the setting of objectives, communication techniques, and the
monitoring of health care delivery with a set of controls such as the
use of treatment guidelines and utilization controls for example. This
table indicates which states regulate managed care; when their
regulations were enacted; the title of the regulations; and what the
nature of the requirements are for managed care organizations. Tables 14
and 15 provide additional details about these regulations. |
|
State |
Effective Date of Managed Care Regulations |
Statutory Cite and Rule Reference |
Approval or Certification Required ** |
Mandatory Elements for Approved Managed Care Arrangements |
|
Numbers and Locations of Medical Providers |
Specialties That Must Be Included |
Utilization Review |
Case Management Services |
Use of Treatment Guidelines |
Internal Dispute Resolution |
Quality Assurance Program |
Patient Education |
Office Staff Education |
Provider Education |
Other |
|
Sample State 1 |
02/09/1995 |
803KAR25:110, "Workers' Compensation Managed Health Care Plans" |
Yes |
x |
|
x |
x |
|
x |
|
|
|
|
Must have medical director, $500,000 in malpractice, financial stability
(may need to post bond), and meet geographical requirements |
|
Sample State 2 |
Managed Care is allowed but not regulated |
|
Notes: |
|
|
** |
Agency Responsibility for Managed Care Regulations: |
|
Arkansas |
|
|
California |
|
|
Colorado |
|
|
Florida |
|
|
Georgia |
|
|
Hawaii |
|
|
Kentucky |
|
|
Minnesota |
|
|
Montana |
|
|
Nebraska |
|
|
Nevada |
|
|
New Hampshire |
|
|
New Jersey |
|
|
New York |
|
|
North Dakota |
|
|
Ohio |
|
|
Oregon |
|
|
Pennsylvania |
|
|
Rhode Island |
|
|
South Dakota |
|
|
Texas |
|
|
Utah |
|
|
West Virginia |
|
