Proposals for change

The Massachusetts Legislature recently began reviewing more than 40 pieces of proposed legislation in a managed care "megabill" aimed at regulating the fast-growing industry. Here's a look at a few of the major proposals:

Access — If a doctor is kicked out of an HMO for reasons other than quality of care, the bill would allow patients to continue seeing the doctor under certain circumstances.

Appeals — Right now HMO members can appeal to health plan officials if they are denied coverage, but HMOs often drag their feet in responding. The bill would require HMOs to respond in a set amount of time, from within 15 days on cases that are not life-threatening to within 48 hours in certain emergency cases.

Choice — The bill would establish a "point of service" option for HMO members that would allow them to see doctors outside the health plan's network and be covered for the amount it would cost within the HMO. The bill also would prevent HMOs from restricting members to psychotherapists and physical therapists within the health plan.

Emergency care — The bill would require HMOs to pay for emergency care that an average reasonable person would seek, even if the illness is diagnosed as not life-threatening. That means if you rush to the emergency room — thinking you have appendicitis that really turns out to be an ulcer — the HMO would still have to pay.

Incentives — The bill would limit the financial incentives HMOs pay doctors that encourage them to withhold or delay medically appropriate treatment or referrals to specialists.

Liability — The bill would prevent HMOs from enforcing contracts with doctors that shield the health plan from all liability for health care decisions. This would eliminate the so-called "hold harmless" provisions in health care contracts. HMOs would then be directly accountable for denying medically necessary care.

Oversight — The bill would establish the Office of Managed Care Quality within the state Department of Health. The office would have the power to intervene on behalf of patients who are denied care and would issue annual report cards on health plans.

Privacy — The bill would prevent health plans from requesting information about the treatment of mental health patients beyond their name, diagnosis, date and type of care requested.