May include clinical protocols or practice guidelines used by an insurer to determine the services or treatments that are appropriate and medically necessary for a person with a specific health condition, disease or illness. The percentage of a provider's fee that the patient is expected to pay. Review conducted during the course of a patient's hospital stay or course of treatment, to determine whether the hospital stay or treatment is still necessary. The process used to determine how a patient's ongoing health care needs will be coordinated and managed after being discharged from a hospital or other health care facility. A Federal law that prevents states from enacting laws or regulations that have an impact on employer welfare plans, including employer sponsored health benefits.
States can regulate insurance carriers or HMOs.
If an employer purchases a regulated health plan, then the members are covered by the state consumer protection laws. Health care items and services needed to screen for or treat an emergency medical condition until the condition is stabilize d, including pre-hospital care and ancillary services routinely available in the emergency department. The document given to HMO members that describes the covered benefits and exclusions, utilization review requirements, cost sharing, and other coverage provisions. The Evidence of Coverage is similar to a policy contract that other insurers issue. A new treatment developed from research that is different from the commonly provided standard of care for a given disease, illness or condition.