What Recourse? — Liability for Managed-Care Decisions and the Employee Retirement Income Security Act

Do Mandates Requiring Insurers To Pay For Emergency Care Influence The Use Of The Emergency Department?

“…13 Mandates also can be confusing and can vary across states, which can sometimes make it difficult for patients and providers to know exactly who is covered, in what circumstances. Their reach is limited by ERISA so that people in self-insured plans are not covered, although our analyses did not provide reason to believe that this was an important factor.…”

Independent External Review of Health Maintenance Organizations' Medical-Necessity Decisions

“…[38][39][40] What the Moran decision clarified is that states are also free to regulate insurance as a way to regulate the practice of medicine and protect the quality of care. There is no doubt that states are free to regulate the quality of medical care and medical practice, because medical care itself does not relate to ERISA plans.…”

Managed Care in Transition

“…Recent judicial decisions suggest that managed-care organizations, although still protected by the act from claims that they must provide specific services (i.e., they cannot be challenged with respect to the scope of the services they provide), can be held responsible under state laws for the quality of the services that are de-livered with their authorization. 21 In addition, managed-care organizations in several states are being sued on the grounds of false advertising. The contention is that although their advertisements state that decisions are made by physicians, in some cases, plans deny coverage for treatments recommended by physicians or require physicians to adhere to guidelines developed by the plans, not by local providers.…”