MISSOURI NO. 2 IN HEALTH LAW

A report from a consumer health care group ranks Missouri second in the nation for laws guaranteeing health care access to managed care customers.

The Families USA Foundation reviewed health care protection laws in all 50 states and the District of Columbia.

Families USA has a list of 13 measures it wants adopted -- all of which are included in U.S. Sen. Tom Daschle's "Patients' Bill of Rights" Act, introduced in the U.S. House of Representatives in March.

Missouri has 10 laws that outline when managed care providers must cover health care expenses.

Those measures would allow managed care consumers to do such things as participate in clinical trials for new medical devices or drugs or sue health care plans for damages.

Ranked highest on the list was Vermont, which has 11 such laws.

Daschle's home state, South Dakota, has no laws relating to managed care coverage and ranks last.

A federal law would provide equal protection to all health-care consumers in managed care plans, said Judy Waxman, director of government affairs for Families USA.

Now, the federal ERISA law -- the Employee Retirement Income Security Act, passed in 1974 -- means that employees of self-insured companies are exempt from those protections, even if they live in states where such laws have been enacted.

As many as a third of Americans with health insurance work for self-insured companies, Waxman said.

Families USA's "Hit or Miss" report outlines what types of protective legislation states offer to managed care consumers.

"When you look at all the holes, we call it hit and miss," Waxman said. "There's some good hits, and many more misses, and a whole third of the population is a total blank."

Too many managed care enrollees are denied coverage of a variety of types of health care, she said.

Waxman said, "The point of the report that we're trying to make is that we need federal legislation because, one, obviously, there are few states that are protecting consumers the way we think is necessary. And, two, even if they did everything on our list, they can't reach everybody in the state because of the ERISA law."

The Missouri Department of Insurance hasn't taken an official stance on Daschle's "Patients Bill of Rights" legislation, said spokesman Randy McConnell.

"Missouri is already clearly ahead of the pack," McConnell said.

House Bill 335, passed in 1997 and now being enacted, contains many of the measures outlined by Daschle and supported by Families USA, he said.

"We have set up the framework that provides a great deal more protection for consumers," McConnell said.

The ERISA exemption is at the heart of the federal health care coverage debate, he said.

"Missouri's example speaks louder than words, because most of what is envisioned in the federal legislation, we already have here," McConnell said. "It is a question of whether the feds will then extend that to people in ERISA plans."

Missouri has enacted these 11 measures, all included in the Daschle's bill and Families USA's agenda:

-- Requiring managed care plans to use the "prudent layperson" standard for coverage of emergency care.

-- Requiring plans to permit access to out-of-network providers if the plan's network is insufficient.

-- Allowing specialists to serve as primary care providers.

-- Allowing enrollees to obtain standing referrals to specialists, rather than requiring a separate referral for each visit.

-- Allowing some enrollees to visit a provider for a specific number of days after that physician leaves the plan.

-- Requiring plans to allow patients to obtain non-formulary -- medications not on a pre-approved list of covered drugs -- prescription drugs.

-- Prohibiting plans from disclosing treatment options to patients.

-- Prohibiting financial incentives for physicians to reduce or deny medical care.

-- Allowing enrollees to sue their insurance plans for damages.

Missouri has not enacted legislation to establish an independent statewide consumer assistance program, as have Florida and Vermont, nor does it require plans to cover patient participation in clinical trials.