2000 Standards of Hemophilia Homecare: P. L. 2000, Chapter 121
At a minimum the standards shall require:
- A carrier must provide homecare service companies that:
- Provide services pursuant to a prescription from an attending physician and not make any substitutions of blood products without the physician's prior approval.
- Provide all brands of clotting factor product, with all assay ranges and needed ancillary supplies.
- Have ability to deliver blood products, medications, and nursing services within three hours during an emergent situation. (PLEASE NOTE: this is complete nursing services including actual home or site visits, not just phone contact or Q&A) and maintain 24 hour on call service.
- Demonstrate knowledge of and experience with bleeding disorders with a minimum of 10 patients within 12 months.
- Demonstrate appropriate record keeping and documentation.
- Provide for proper removal and disposal of hazardous waste material.
- Provide covered person with written policy regarding discontinuation of Services related to loss of coverage.
- Provide covered persons with information on costs of medications and services, if requested, that are not covered by individual's health plan.
- A carrier shall provide payment for services to the clinical lab at a hospital with a state recognized hemophilia care center if the covered person's attending physician determines that use of the hospital's clinical lab is necessary because:
- Test results are medically necessary immediately or sooner than the normal return time for carrier's participating lab.
- Accurate test results need to be determined by closely supervised procedures in venipuncture and lab techniques in controlled environment that cannot be adequately achieved by carrier's participating lab.
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1992 Healthcare Reform Act:
- Provides coverage for everyone; no one can be denied for a pre-existing condition.
- Pre-existing exclusion clause time period (up to 1 year is allowed) can be waived if proof of uninterrupted coverage for that time period is shown.
- Coverage must be found 30 days after termination for individual plans; coverage must be found 60 days after termination for group plans.
1997 HMO Regulations:
- It is mandated in subchapter 6 (Provider Services), section 3 (Tertiary and Specialized Services), Number 6 . . . "that the HMO must have a policy assuring access to specialty outpatient centers for hemophilia (pediatric and adult) and to prescribed treatment regimens . . . "
- Under "provider network" it also states . . . "at discretion of HMO, exceptions may be made for appropriate medical specialists to be designated as primary care providers for specified individuals or patient groups who, due to health status or chronic conditions, would benefit from medical care management by such a medical specialist . . . "
2001 Healthcare Accountability Act P. L. 2001, Chapter 187
- Persons covered under a health or dental benefits plan can sue their carrier or an organized delivery system for loss that occurs (economic or non-economic) as a result of a denial or delay in approving or providing medically necessary covered services.