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HMOs face tighter restrictions

Families USA Foundation, a national advocate for health-care reform, says consumer complaints have helped push Florida and other states to step up regulation of managed health-care programs.

"There was a surprising amount of legislation enacted in a very short period of time, even in an anti-regulatory environment," said Ron Pollack, executive director of Families USA, a Washington, D.C., consumer group.

In Florida, three new laws will go into effect this year. The new rules range from stopping marketing abuses by HMOs that serve Medicaid patients to setting standards for insurance coverage of hospital stays after childbirth.

Another new rule will require HMOs to cover emergency room tests. At times, hospitals such as St. Anthony's in St. Petersburg have trouble getting HMOs to reimburse emergency room care because patients were deemed healthy enough to wait for office visits, said Ford Kyes, director of operations.

Gov. Lawton Chiles vetoed a fourth bill that would have let HMO patients sue their health plans over their refusal to provide specialists or other care.

That bill would have also forced the plans to disclose bonus plans that reward doctors for limiting care and prohibited "gag clauses" that require doctors to keep silent about treatments that HMOs won't allow.

Florida still lags some others in patient rights laws, Families USA said. Elsewhere, lawmakers have guaranteed the right to see local specialists, forced HMOs to contract with doctors who meet their standards and required HMOs to make more prompt decisions about the care they will cover.

Karen Ignagni, president of the Washington-based American Association of Health Plans, which represents about 1,000 managed care plans, said HMOs support some consumer protection.

But she added that over-regulation of the industry hurts the economics of managed care, which saves about 15 percent of the cost of care partly by limiting consumers' choices.

_ Information from the Associated Press was used in this report.