[20020627]RS20845_托管护理和州外部审查法规.pdf

1 See Consumer Grievance Procedures: Internal and Independent Appeals, Health PolicyTracking Service, National Conference of State Legislatures (April 2002).2 536 U.S. _ (2002).Congressional Research Service The Library of CongressCRS Report for CongressReceived through the CRS WebOrder Code RS20845Updated June 27, 2002Managed Care and State External Review StatutesAngie A. WelbornLegislative AttorneyAmerican Law DivisionSummaryThis report discusses ERISAs existing procedure for reviewing the adversecoverage determinations of participants in employer-sponsored group health plans. Thereport also reviews the recent decision by the Supreme Court involving the preemptionof state external review statutes and legislative proposals in the 107th Congress to amendERISA to require external review. This report will be updated in response to relevantlegislative and judicial activity.Currently, forty-two states and the District of Columbia have either legislation orregulations in place concerning an independent review process for enrollees in healthplans.1 In Rush Prudential HMO v. Moran, the Supreme Court concluded that an Illinoisstatute requiring health maintenance organizations (“HMOs”) to