Mid-Atlantic Health Law TOPICS

While Congress is wrangling over a federal Patients' Bill of Rights, it should be remembered that Maryland passed its own Patients' Bill of Rights Act in 1999. The Maryland Act went into effect on October 1, 1999, for new insurance policies. Existing insurance policies and plans need not comply with the Maryland Act until October 1, 2000.

The Maryland Act has two objectives, namely (A) helping consumers obtain information about insurance companies and HMOs, and (B) enhancing patients' access to care.

 A. Information

The Maryland Act creates a Consumer Education and Advocacy Program within the Maryland Insurance Administration to be an information clearing house regarding the myriad of agencies involved with the delivery of care by "carriers" (for example, insurance companies and HMOs). This Program also will provide consumers with assistance in filing complaints.

B. Access to Care

With respect to access to care, the Maryland Act requires carriers to offer access to both in-network and out-of-network specialists under certain circumstances.

Carriers that do not allow access to in-network specialists without a referral from a primary care physician must provide for a standing referral to an in-network specialist, if the patient's condition requires specialized medical care and is life threatening, degenerative, chronic or disabling. Notwithstanding such standing referral, the patient's treatment plan may limit the number of visits to the specialist and the period of time in which such visits are authorized.

In addition, carriers must permit referrals to out-of- network specialists, if the patient's condition requires specialized care, the carrier does not have a specialist with the appropriate expertise in-network, and the specialist agrees to accept the same reimbursement as would be provided to an in-network provider.

The Maryland Act also addresses formularies, which are lists of drugs or devices accepted for reimbursement by the particular health plan. The Maryland Act provides that a carrier must also cover out-of-formulary drugs and devices, if the prescriber determines there is no equivalent prescription drug or device in the formulary, or the equivalent in the formulary has been ineffective or is likely to cause an adverse side effect.

Last, carriers must provide at least one home visit (and a second if prescribed), when a patient has a mastectomy or the surgical removal of a testicle, as an outpatient or spends less than 48-hours in the hospital.