Managed Care: State Regulation
Managed Care: State Regulation is a concise softcover reference manual that summarizes and catalogues the vast number of state regulations and statutes that managed care organizations and health care insurers must currently follow to improve and protect the health of patients as well as to avoid sanctions and possible litigation. It is part of a collection of reference manuals in health care law compiled by the attorneys and editors of Aspen Publishers' Health Law Center that addresses such issues as health care fraud and abuse, physicians as employees, employment discrimination, and employee benefits.
The first 24 pages are divided into clearly written summaries of the issues and regulations affecting contracts with providers, contracts with enrollees, mandatory coverage, and operations of managed care organizations. Topics such as any-willing provider-freedom-of-choice laws, provider due process, gag clauses, and financial incentives are covered in the section on contracts with providers. Preexisting conditions, confidentiality, appeals of denials of coverage, and termination and continuation of coverage are covered in the enrollee-contract section. The mandatory-coverage section deals with legislatively mandated benefits such as mental health parity, experimental treatments, and maternity length of stay.
The remainder of the book consists of nine appendixes that contain clearly written, comprehensive tables, by state, of almost every issue that legislators have attempted to regulate. Included are tables on statutory authorities, administrative regulations affecting health maintenance organizations, mandated benefits, quality assurance, reserve and capital requirements, solvency protection, and financial reporting. The tenth appendix, for reasons not entirely clear, completely reprints the Comprehensive Health Insurance and Health Care Cost Containment Model Act.
Although clearly organized and well written, much of this manual's content will be of little interest to the average practicing mental health professional. It seems targeted at managed care administrators, attorneys, and health care professionals who may be thinking of geographic expansion or who have a need to understand the existing regulatory framework in their own or a host of other states. Health care providers who are contemplating contracts with managed care organizations or who want a brief overview of the regulatory issues affecting managed care organizations may also find the book useful.
Dr. Rofman is medical director of the Massachusetts Behavioral Health Partnership and associate professor of psychiatry at Boston University School of Medicine.
