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September 20, 2000
 
BREAKTHROUGH AGREEMENT REACHED ON COMPROMISE MANAGED CARE REFORM BILL
 
WASHINGTON, DC – The Bipartisan Consensus Managed Care Improvement Act of 2000 was released today for consideration by House and Senate members by U.S. Representative Charlie Norwood (R-GA).

The full text of the draft legislation, co-authored by U.S. Representatives Charlie Norwood (R-GA), John Dingell (D-MI), and Greg Ganske (R-IA), was formally released in order for House and Senate members and the public to have adequate time to consider the compromise legislation before Congress considers the matter later this month. 

“Legislation that will so dramatically impact the health care of all Americans should not be brought forward and voted on before members even have a chance to see it, much less read or study it,” says Norwood.  “By this release today, members and the American people will have time to carefully study this document before the House and Senate face this important issue.” 

Norwood and Dingell, co-authors of the House-passed HR 2723, have worked with House and Senate members, leadership of both parties, and the White House since late May to develop a compromise plan for use as a final conference report.  The new proposed legislation is supported by the American Medical Association. 

The full text of the legislation, along with a summary and legislative comparisons chart are available through Norwood’s office or on the Internet at http://www.house.gov/norwood

Norwood-Dingell as passed v. the Alternative
Issue
Norwood- Dingell, HR2723
The Alternative
Language Source for the Alternative
Grievances and Appeals
     
Utilization review and standards
Norwood-Dingell
Internal Review
The Nickles Amendment
External  Review
The Nickles Amendment
Grievance Process
 
N/A
Access to Care
     
Consumer Choice Option
Norwood-Dingell
Choice of Health Professional
Norwood-Dingell
Access to Emergency Room Care
Coburn-Shadegg
Access to Ambulance Services
 
Coburn-Shadegg
Access to Specialists
The Nickles Amendment
Access to Obstetricians and Gynecologists
The Nickles Amendment
Access to Pediatricians
The Nickles Amendment
Continuity of Care
The Nickles Amendment
Access to Non-formulary Drugs
The Nickels Amendment
Clinical trials for all life-threatening conditions
Norwood-Dingell
Coverage for mastectomy length of stay and breast cancer second opinions
 
The Nickles Amendment
Access to Information
     
Patient Access to Information
The Nickles Amendment
Protecting the Doctor-Patient Relationship
     
Gag Rule
Norwood-Dingell
Nondiscrimination against providers
The Nickles Amendment
Restriction on Incentive Plans
Norwood-Dingell
Prompt payment on claims
Norwood-Dingell
Due Process for Health Professionals and Providers
Norwood-Dingell
Whistleblower protections for health professionals
Norwood-Dingell
New Language Pieces in the Alternative
Issue Norwood-Dingell, HR2723 The Alternative
Scope
Americans covered by the bill All Americans in private insurance are covered using the HIPAA mechanism, Which requires all states to conform to the federal law All Americans in private insurance are covered by the bill or a state can seek to certify that an existing state law is substantially equivalent to a provision
Accountability for Decision Makers
Federal Liability for Health Plans None Allows a plan to be held liable in federal court for decisions that do not involve medical judgment
State Liability for Health Plans Allows a plan to be held liable for their decisions that cause injury or death to a patient in a state court of law Allows a plan to be held liable in state court for decisions of medical judgment that injure of kill a patient
Protection for the development of case law None specifically written into the bill Language written to ensure that recent Supreme Court decisions are not overturned
Protection for employers Protects employers frim being held liable unless they exercised discretionary authority in making a decision Protects employers from being held liable unless they directly partcipate in making a decision; language developed from Coburn-Shadegg Substitute
Limitations on damages Punitive damages are prohibited if a plan followed the determination of the external review entity For the federal and state causes of action, punitive damages are prohibited unless the plan acts willfully or wantonly

The Bipartisan Consensus Managed Care Improvement Act of 2000
September 20, 2000

A Plain Language Summary

1. Scope
All new health plan standards apply to all plans, an estimated 191 million Americans.  The standards can be enforced by the states or the federal government, at the discretion of the states.  The states are further empowered to waive specific federal standards in favor of substantially similar state standards.  The Department of Health and Human Services can challenge the state position if HHS feels the state standards are inadequate. 

2. Liability
 Jurisdiction: Shared Federal/State
        State Remedy – Medically-reviewable decisions. If an independent benefit review entity determines the patient and/or requested benefit is included in the plan, legal remedy is in state court. 

        Federal Remedy – If the benefit review panel cannot determine that the requested patient and/or benefit is included in the plan, suits for injury are federal court jurisdiction. 

        Damages - Economic, pain-and-suffering, and punitive damages are available in both federal and state court.  Punitive damages are strictly limited to specific conditions. If the plan met the timelines, and abided by the decisions of the external appeals panel, punitive damages are prohibited. 

        Exhaustion of Administrative Remedies -  Once a patient suffers physical injury, they can sue regardless of their status in the appeals process.  However, if an external medical review is requested by either party, the review must be completed. 

        Patient’s Right To Sue Without Injury - If the plan refuses to abide by the external appeals ruling, but the patient is not injured, the patient can still sue in federal court for $1000 a day for every day that care was denied with no limit, plus attorney fees and court costs. 

        Reinforcement of Justifiable ERISA Liability Shields 

        Approved Treatments: If a plan or employer approves a patient’s request, they remain shielded from liability. 

        Direct Participation: If an employer does not directly participate in a dispute, they are shielded from all liability. 

        Choice of Plan Or Benefits: Employers cannot be sued for their choice of health plan, or benefits package. Insurers cannot be sued for excluding specific benefits in their plan.  Employers remain shielded from all liability when offering defined contribution plans. 

        Class Actions:  No class action suits may be brought under these ERISA liability reform provisions. 

3. The Appeals Process

        Up-Front Medical Review: Patients and their doctor must be able to talk to a health plan doctor, not just an insurance clerk, when a plan denies coverage. 

        Benefit and Medical Necessity Review Panels: If the plan still denies coverage, the patient can demand an independent review. The dispute must be initially referred to an independent benefit review entity, which will determine whether the requested benefit, and the patient, is a part of the plan.  If the panel finds for the patient, the dispute is referred to an independent medical review panel, whose final decision is legally binding on the plan.  Medical and contract review panels must be certified as independent by the Secretary of Labor. 

        Filing Fee: A $25 filing fee for external review.  Fee is waived if the patient is indigent.  Further, the appeal must move forward regardless of whether the patient pays. 

        Timelines: Urgent Care: 72 hours. Non-urgent care a maximum 75 days from initial request to final external appeal panel decision, unless the patient requires more time. 

4. The Freedom To Choose A Doctor 

Every American should be able to choose their doctor and hospital, and change their decision on a regular basis if they feel the need.   The responsibility for providing a choice option lies with the insurance company, not the employer. 

5. Specialists 
Every American should be able to see a specialist if their doctor thinks they need one. 

6. Obstetricians, Gynecologists, and Pediatricians
Women should be able to see obstetricians and gynecologists without any referral.  Children should be able to see pediatricians, without any referral, as their primary physician. 

7. Continued Care
Patients should not be forced to change doctors and hospitals while being treated for a problem. 

8. Guaranteed Emergency Room Care
Patients should be able to go to the nearest emergency room when they think they have an emergency, and should pay no more out-of-pocket than they would have at their health plan’s designated hospital. If the problem reasonably appeared to be an emergency, but turned out not to be, the insurance plan still has to pay. 

9. Clinical Trials Reform
Patients should be able to participate in clinical trials without undue interference from their health plan.   The health plan is not forced to pay more for clinical trials than they would have paid for regular care. 

10. Drug Formulary Reform
Patients should have the right to insist on their doctor’s prescribed drug, if their doctor determines that the specific drug is necessary over the health plan’s designated drug. 

11. Incentives To Deny Care 
No health plan may provide payment incentives for doctors or hospitals to deny care.   However, reasonable capitation plans are allowed, as defined under current federal law.

12. Readable Contracts 
Every American should be able to clearly understand what benefits are covered by their health plan, before they agree to the coverage.  Plans should provide specific information in laymen’s terms, including information on the rights of patients to challenge plan decisions. 

13. Privacy 
No medical information on a patient should be released without the patient’s approval. 

14. Freedom Of Communication
Every doctor should be free to discuss anything relative to a patient’s health with the patient, even if the information may be negative towards the health plan.  Health plans should not fire or discipline doctors for talking freely with their patients, or discriminate against doctors for past cooperation in patient advocacy.

15. Nondiscrimination
Plans cannot discriminate against providers in allowing participation based on nothing more than the type of license held by the provider, as long as the provider is licensed to provide the service in the particular state.  However, varying reimbursement rates for different levels of training are not affected by this provision

16. 100% Tax Deductibility of Health Premiums for the Self-Employed
Self-employed Americans will be afforded the same 100% tax deductibility of health premiums as is currently enjoyed by businesses, beginning in 2001. 

17. Medical Savings Accounts
The current sunset provision on MSA’s for December 31 of this year is extended another four years.  The restriction of medical savings accounts to businesses with fewer than 50 employees is doubled, to include businesses with up to 100 workers.  The overall cap of 750,000 policies is increased to 1,000,000 policies.  The General Accounting Office would conduct research to determine whether this expansion of MSA’s leads to adverse selection or any skewing of the insurance risk pool. 

18. Incentives for Small Businesses to Provide Health Care Coverage
The bill provides a tax credit for the purchase of health insurance for small employers (2-50 employees) who have previously not offered coverage.  The basic credit would be equal to 20% of the costs of providing insurance coverage, but would be 30% for coverage purchased through a small business purchasing pool.  The credit would apply to individual coverage up to $2,000 and $5,000 for family coverage.  It would be available for the first 48 months that the employer purchases insurance.

The bill provides for foundation grants to qualified health benefit purchasing cooperatives would be treated as a grant or loan for charitable purposes. Expenses covered would include all ordinary and necessary expenses for the establishment of the cooperative within the first 24 months of its creation.  Finally, the bill would provide $500 million over 5 years in new federal grants for state health insurance coverage expansions.
 

 
 
CONGRESSMAN CHARLIE NORWOOD       1707 LONGWORTH BUILDING      WASHINGTON,DC 20515 


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