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Health Care Bulletin #132

Bulletin
Tuesday, February 15, 2011
Health Care Bulletin #132

Bulletin HCA- 132

Consumer Protection and Quality Requirements for Managed Care Organizations

Rule H-2009-03, Section 3.2(G)(4)(e) (Effective 12/17/2009)

February 15, 2011

Authority: The Commissioner is authorized to issue this Bulletin pursuant to 8 V.S.A. § 15.

This Bulletin explains the Division's position concerning Section 3.2(G)(4)e of Rule H-2009-03. That section requires that a managed care organization (MCO) provide a member, in an adverse benefit determination letter (ADL) issued in connection with a concurrent or pre-service review, a statement of "what, if any, alternative covered benefit(s) the managed care organization would consider to be medically necessary and would authorize if requested."

Questions having arisen regarding the validity, application and interpretation of Section 3.2(G)(4)e, the Division will accept language in the ADL that the member is strongly advised that he or she should discuss alternative treatments with his or her treatment provider.

Stephen W. Kimbell Commissioner