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The regulations, which Secretary Thompson pledged to have in place by early next year, will guarantee Medicaid beneficiaries access to emergency room care, a second opinion when needed, a timely right to appeal adverse coverage decisions, and other essential patient protections. At the same time, the rule will give states flexibility to provide these protections in a workable manner.

"Medicaid beneficiaries deserve the same rights and protections as all other Americans enrolled in managed care plans," Secretary Thompson said. "This proposed rule provides needed patient protections and gives states flexibility to implement these protections without jeopardizing Medicaid beneficiaries' access to health care."

The proposed regulations build on protections for Medicaid beneficiaries that were created under the Balanced Budget Act of 1997.

The proposed rule retains and expands upon all the protections already available to Medicaid beneficiaries under the 1997 statute. Under the rule, beneficiaries will have the following rights:

• Emergency Room Care. Health plans must pay for a Medicaid beneficiary's emergency room care whenever and wherever the need arises.
• Access to second opinion. All beneficiaries will be allowed to get a second opinion from a qualified health professional.
• Direct access for women's health services. Women will be allowed to directly access a woman's health specialist in the network for the care necessary to provide routine and preventive health care services as already available in Medicaid fee-for-service.
• Patient-Provider Communication. Managed care plans will be prohibited from establishing restrictions, such as gag rules, that interfere with patient-provider communications.
• Network Adequacy. Managed care plans will be required to assure that they have the capacity to serve the expected enrollment in their service area.
• Marketing Activities. States will be required to approve marketing materials used by the managed care plans to enroll Medicaid beneficiaries. Plans are prohibited from using door-to-door, telephone, and other forms of "cold call" marketing.
• Grievance Systems. All managed care plans must have a system in place to accommodate enrollee grievances and appeals. Grievances must be resolved within state established timeframes that may not be longer than 90 days and must be resolved by managed care organizations within 45 days. However, expedited timeframes exist for resolving appeals when the life or health of the enrollee is in jeopardy.

Managed care plans serving Medicaid beneficiaries also must provide consumers with comprehensive, easy-to-understand information about the managed care plan in which they are enrolled.

The proposed regulations will replace a rule put forth by the Clinton administration last January. Under the new regulations, states will have significantly more flexibility to decide how best to provide patient protections and use managed care in their Medicaid plans. The new rule's provisions are more concise and understandable and will reduce the regulatory burden on the states and health plans.

In addition, the rule will allow states, many of which have already implemented protections through state laws and regulations, to keep in place important aspects of their existing programs. The new rule also will require states to submit to HHS clear plans for providing beneficiaries with high quality care and to measure the quality of the care that is actually provided.

"I want to have patient protections in place as quickly as possible. However, the previously issued rule went far beyond what Congress intended with the Balanced Budget Act, and its excessive mandates actually threatened beneficiaries' access to care under Medicaid," Secretary Thompson said. "The new proposed rule will ensure that states have the flexibility they need to protect patients while protecting the programs they may already have established."

The proposed regulation will be published in the Federal Register on Monday, Aug. 20 and will be available online today at cms.hhs.gov/medicaid. The 60-day comment period for the proposed rule will end on Oct. 19, 2001. CMS will review those comments for the final regulation, which will be issued early next year.

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