Assembly Joint Resolution No. 15–Committee on

Health and Human Services

FILE NUMBER........

Whereas, On May 19, 1998, testimony was presented to members of

the United States Senate Committee on Labor and Human Resources by the

Honorable Marilyn R. Goldwater, Deputy Majority Whip in the Maryland

House of Delegates, urging members of Congress to strengthen

requirements for the appeals processes for plans covered by the Employee

Retirement Income Security Act of 1974 (ERISA); and

Whereas, In her presentation, Ms. Goldwater noted that it is important

to have strong, effective and responsive internal grievance and appeal

mechanisms in place; and

Whereas, Every state requires managed care entities to have an internal

appeals process in place; and

Whereas, If it is determined that a federal external appeals process is

appropriate, it should be administered by the Federal Government

according to rules established by federal law, with states managing those

plans under their regulatory authority; and

Whereas, Several states have enacted legislation to revise and refine

both the internal and external appeals processes; and

Whereas, In Maryland, legislation was enacted to strengthen the state’s

internal grievance and appeals processes, establish an external appeal

mechanism and provide additional regulatory authority to the state’s

insurance commissioner over medical directors in health maintenance

organizations; and

Whereas, In Florida, the nation’s first external review process was

created in 1985, and Florida continues to fine tune its process by utilizing a

panel of six state employees for the external review process, with explicit

time frames from "extreme emergency" cases to "nonurgent" cases; and

Whereas, New Jersey enacted legislation in 1997 that requires health

maintenance organizations to establish an external appeal process and now

operates a consumer hot line for consumer questions and complaints; and

Whereas, Texas enacted landmark legislation in 1998 that permits

managed care enrollees to sue their health plans for malpractice in cases

where they have been harmed by a plan’s decision to delay or deny

treatment; and

Whereas, According to The Best From the States II: The Text of Key

State HMO Consumer Protection Provisions by Families USA Foundation

(October 1998), key consumer protection provisions include the

establishment of explicit time frames for appeal of decisions,

implementation of methods for expediting the review of emergency and

urgent care situations, acceptance of oral appeals and adoption of laws that

require reviewers to be health care providers with expertise in the clinical

area being reviewed and that prohibits reviewers from participating in the

review of cases in which they were involved in the original decisions; and

Whereas, On February 9, 1999, in a letter to the editor of the Las

Vegas Sun, Marie Soldo, immediate past Chairman of the Nevada

Association of Health Plans, wrote that, because the state has limited

jurisdiction regarding the regulation of health insurance plans, more than

two-thirds of Nevadans, including state and federal employees, Medicare

and Medicaid enrollees and others whose employers are self-insured, are

not affected by state legislative action such as mandated benefits, improved

grievance and appeals processes and the proposed ombudsman office; now,

therefore, be it

Resolved by the Assembly and Senate of the State of Nevada,

Jointly, That the Nevada Legislature hereby urges Congress to take steps

to ensure that those plans which are exempt from state regulation provide

adequate protection provisions for persons covered by such health plans;

and be it further

Resolved, That the Chief Clerk of the Assembly prepare and transmit a

copy of this resolution to the Vice President of the United States as the

presiding officer of the Senate, the Speaker of the House of Representatives

and each member of the Nevada Congressional Delegation; and be it

further

Resolved, That this resolution becomes effective upon passage and

approval.

~