tions' compliance with federal law. The Medicare statute sets standards for hospitals, nursing homes, home health agencies, and other providers that the states are primarily responsible for applying and enforcing. Because state HMO licensure is currently required for Medicare risk contracts, it forms a floor for solvency and other standards and provides jurisdiction for state managed care regulators to monitor compliance with consumer protection standards. As the number and types of Medicare risk-bearing health plans increase, this relationship could be formalized so that states monitor compliance with federally established standards. As it does for health care facility certification, the federal government could oversee state performance of this responsibility and accept consumer complaints. Government standards and periodic audits could be coordinated with private accreditation to the extent that private standards serve Medicare consumer interests.

Proposed Statutory Changes in Medicare Managed Care

As part of a restructured Medicare program, the U.S. Congress considered changes to current policy regarding enrollment in or standards for managed care organizations. Some of these proposals could have enhanced consumer protections. For example, as discussed above, the conference bill would have required the federal government to provide comparative plan information on benefits, premiums, and quality indicators. The U.S. Senate's version of the bill (but not the conference bill) would have required an expedited process of appeal to HCFA for disputes over services or payment that would result in "significant harm" to an enrollee.

On the other hand, several of these proposals would not benefit Medicare consumers. Door-to-door solicitation and gifts to encourage enrollment would no longer have been prohibited, which would likely lead to marketing abuses found in Medicaid managed care enrollment more than 25 years ago (D'Onofrio and Mullen, 1977) and Medicare Supplemental markets before 1990 congressional changes (U.S. General Accounting Office, 1991). Substituting accreditation (which typically involves review only every 2 or 3 years) for currently required annual ex-



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