mates, and historical trends (U.S. General Accounting Office, 1993a).

Several state HMO licensure laws address common Medicare health plan enrollee complaints (Dallek et al., 1995) and could serve as models to strengthen Medicare risk contracting standards. Some involve enrollee information, which could be especially useful in view of the fact that as many as 25 percent of Medicare HMO enrollees do not seem to understand plan constraints and procedures. For example, Florida requires that an HMO employee not in the marketing department verify that each new enrollee intends to enroll and understands the HMO's restrictions. (One of the Medicare plans whose administrator was interviewed for this paper contacts each Medicare enrollee by telephone after receiving HCFA confirmation of enrollment to discuss lock-in, appointment procedures, and other plan features and requirements.) Minnesota requires HMOs to explain that the listed providers may not be accepting new patients. Arizona requires plans to provide enrollees information on how to obtain referrals and whether provider compensation programs include incentives or penalties to encourage withholding of services or referrals.

Few state laws regulate health plan features that make obtaining care more convenient, but several require that appointments be available within a "reasonable" time. Florida law requires that patients be seen within an hour of their scheduled appointment times except when delay is "unavoidable." Several states address issues of access to care. About half have a general requirement that HMOs have a sufficient number of physicians to serve enrollees. California, Delaware, Pennsylvania, and South Dakota establish specific primary care physician-to-enrollee ratios. Because access to specialists involves both network capacity and the willingness of gatekeepers to refer, Minnesota requires that referrals be made in accordance with accepted medical practice standards. Several states prescribe maximum travel time or distance. For example, Minnesota requires that primary care providers and general hospitals be located within the lower of 30 miles or 30 minutes from enrollees and that other providers be available within 60 miles or 60 minutes.

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